Adapalene and Benzoyl Peroxide

I agree, in the form of a declaration, given under oath and penalty of perjury, that I:

General Information

• am 18 years or older and I am the legal owner of the pet for which this declaration is being submitted. I am doing so voluntarily, and have provided accurate and complete demographic information including, but not limited to my valid name, address, shipping address, IP address, and location I am visiting this website from, along with my pet’s name, species, breed (if applicable), sex, age, and weight.
• will only use this service provided through this request to seek a prescription for my pet, and I will administer it as prescribed. I will not provide any prescribed medicine I receive for my pet to any other animal or person.
• understand that this attestation is made under oath will be reviewed and relied on by a veterinarian licensed in my state (the “Telehealth Provider”). I acknowledge that the name of the Telehealth Provider responsible for reviewing my attestation and making a prescribing decision, along with their credentials, were disclosed and made available to me prior to submitting this declaration. I reviewed this information by visiting the Consent to Veterinary Telehealth page on the TelyRx.com website prior to completing this declaration.   
• acknowledge and agree that a valid veterinarian-client-patient relationship (VCPR) between me, my pet, at the veterinarian identified in the Consent to Telehealth exists and that it was established via my submission of medical and personal information though this portal, which was prior to the provision of any telehealth services or prescribing decision. Moreover, I know that the consultation via asynchronous telemedicine technology, i.e., the virtual visit, may be supplemented by additional written or oral questions/instructions from the veterinarian using synchronous methodologies such as phone and/or video calls should the need arise, and the applicable standard of care in my state is being met by this telehealth methodology in accordance with applicable law.
• understand that prescribing medications via telemedicine is at the sole professional discretion of the veterinarian just as is the case during in-person care. The indication, appropriateness, and safety considerations for each prescription issued during this telemedicine encounter, and the number of refills, if any, will be evaluated by the Telehealth Provider consistent with any applicable state and federal laws, as well as current standards of practice in your state.
• understand and acknowledge that I am responsible for reviewing the terms and conditions relevant to this telehealth encounter located at: https://telyrx.com/terms-conditions and by proceeding further with this attestation  I understand and agree to be bound by the Terms and Conditions.

Consent to Telehealth

• understand and acknowledge that this telehealth model is a supplemental modality of care intended for my convenience, and the Telehealth Provider is not to be used, or relied on, as a replacement for in-person follow-up visits or in-person interactions with my pet’s primary veterinarian.
• understand and acknowledge that due to the nature of telehealth, the VCPR with the Telehealth Provider terminates at the end of the virtual visit and the Telehealth Provider is not able to: (1) monitor my pet’s ongoing health or lab values for side effects or efficacy, (2) observe how my pet tolerates any prescribed treatment, or (3) determine if the prescribed treatment is working as intended and am being reffered to . I am aware of these limitations and nevertheless assume any risks associated with this modality of care and waive any claim I may have in the future against TelyRx and/or the Telehealth Provider.
• understand and acknowledge that by using TelyRx and providing this attestation to the Telehealth Provider, I have created a veterinarian-client-patient relationship via this encounter, am providing informed consent to use this telemedicine technology, and I am being directed by the Telehealth Provider to consult my pet’s veterinarian immediately after beginning any treatment prescribed by the Telehealth Provider for follow up or to address any adverse reactions because the veterinarian-client-patient relationship created by this telehealth encounter terminates at the end of this virtual visit (and/or receipt of the prescription, if appropriate). I also understand that I am being referred to the veterinarian who is identified when I search for my zip code on the FVMA site at https://fvma.org/membership/find-a-vet/
• agree that the Telehealth Provider determines, in conjunction with applicable laws, whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter.
• understand that TelyRx takes appropriate security measures in conjunction with the use of this telemedicine technology, such as encrypting data, enabling password protection of data files, and/or utilizing other reliable authentication techniques, but recognize there remain potential risks to privacy notwithstanding such measures, but I understand that no system is fully secure. I waive any claims for breaches or data loss caused by technical failures.
• hold TelyRx and the Telehealth Provider harmless for information lost due to technical failures and provide my express consent for TelyRx and the Telehealth Provider to transmit patient-identifiable information to associates in order to provide the services sought, if done so consistent with state and federal law.

Clinical Information About My Pet Specific To The Drug I Am Requesting

• am using this medication as indicated for the topical treatment of acne vulgaris
• have been previously prescribed this medication for the treatment of acne vulgaris by an authorized healthcare provider
• have not had a hypersensitivity reaction to adapalene, benzoyl peroxide, or any component of the formulation
• understand that this medication is for external use only and should not be applied to mucous membranes or areas of broken skin
• am aware of the potential for skin irritation and will monitor for signs such as erythema (redness), dryness, scaling, burning, or stinging, especially during the first 4 weeks of use
• understand to avoid using other potentially irritating topical products concurrently, such as medicated or abrasive soaps and cleansers, and products with high concentrations of alcohol
• understand that benzoyl peroxide may bleach hair, colored fabrics, or carpeting and will take precautions to avoid contact with these items
• understand the need to use sunscreen and protective measures to minimize sun exposure due to increased photosensitivity associated with this medication
• do not have a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis
• do not have viral diseases of the skin such as varicella
• am aware to discontinue use and consult my healthcare provider if significant skin irritation or allergic reactions occur

Additional Representations Concerning My Pet’s Clinical History, Behavioral and Physical Information

• my pet is generally in good health apart from the condition(s) I am seeking medicine(s) for and is not in immediate distress.
• my pet is not pregnant or nursing.
• my pet has not been exhibiting abnormal behavior.
• agree that this attestation accurately reflects the accurate medical and medication history of my pet. It is presented in a manner that is sufficiently complete that I would not seek to add any additional information and thus enables the prescribing Telehealth Provider to make an informed prescribing decision. I confirm that all medical information relevant to this telehealth encounter, which I would typically share during an in-person visit or through using synchronous technology is encompassed in or covered by the representations contained in this attestation. Should I have the opportunity to provide additional information, I would have no additional relevant information to provide. However, the Telehealth Provider may still ask follow-up questions or seek further history, including through video means, if necessary to gather sufficient information for making a prescribing decision.

General Information About Prescription Drugs

• understand and acknowledge this attestation does not provide a comprehensive list of precautions, risks, side effects, or details regarding the administration of this medication. Additional information can be found at www.fda.gov. I accept the risk that administering this medication to my pet may result in one or more of the side effects listed at www.fda.gov.
• understand and acknowledge that only major drug interactions are listed in this attestation and interactions have not been reviewed against the other medications, supplements, or herbal products my pet may be taking unless they were also dispensed by TelyRx.
• understand and acknowledge that drug interactions have not been reviewed against other substances my pet may be taking unless those were disclosed. I accept responsibility for disclosing all relevant information.
• understand and acknowledge that I can find more information regarding the way the medication I am seeking for my pet interacts with other drugs at www.drugs.com/vet/ or www.fda.gov and can report adverse side effects at https://www.fda.gov/animal-veterinary/product-safety-information/adverse-event-reports-animal-drugs-and-devices.
• understand and acknowledge that I should consult additional resources, the information provided with the prescription, and/or ask my pet’s primary veterinarian if I have additional questions concerning potential interactions, precautions, risks, side effects, or details about taking this medication before proceeding with its use.

Pharmacy Information

• understand and acknowledge that TelyRx, LLC is a licensed pharmacy, does not provide medical care or medical advice, and the independent Telehealth Provider who uses TelyRx.com to provide telehealth services acts separately from and is not employed by TelyRx and should not replace your pet’s primary veterinarian.
• understand and consent to receiving pertinent education information regarding the medication my pet may be prescribed via electronic means and receive information about refills, if any, via electronic means.
• understand and acknowledge my responsibility to thoroughly review the information contained in this attestation. If I have additional questions or concerns, I will contact the Telehealth Provider or my pet’s veterinarian before administering any medication to my pet prescribed through TelyRx.com.

Seek Help in Case of Emergency

• understand and acknowledge that neither TelyRx nor the Telehealth Provider can provide emergency care or crisis intervention. In the event of an emergency, I understand that I should immediately contact the emergency animal clinic or animal hospital that is identified when I search for my zip code on the FVMA site at https://fvma.org/membership/find-a-vet/

By electronically signing and submitting this declaration, which is a valid and binding signature under the federal E-Sign Act and state UETA analogues, I certify under penalty of perjury that the above statements are true and complete, and that I understand the scope and limitations of receiving veterinary telemedicine services for my pet through TelyRx.