Cold And Flu Medication Kit

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 am completing this attestation for myself, doing so voluntarily, and have provided accurate demographic information including, but not limited to my valid name, address, IP address, and location I am visiting this website from, along with accurately reporting my sex assigned at birth, height, and weight.

• will only use this service to seek a prescription for myself, will use it as prescribed, and will not provide any prescription medicine I receive to any other person.

• understand that this attestation under oath will be reviewed and relied on by a doctor licensed in my state (the “Telehealth Provider”) and that the name of the Telehealth Provider who will be responsible for reviewing my attestation and making a prescribing decision, along with his or her credentials, was available to me and I reviewed it by visiting the Consent to Telehealth page on the TelyRx.com website before completing this attestation.

• understand that prescribing medications via telemedicine, as is the case during in-person care, is at the professional discretion of the physician. 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 in accordance with state and federal laws, as well as current standards of practice in your state.

• agree a valid physician-patient relationship is being established via this asynchronous telemedicine technology, that the virtual visit may be supplemented by additional questions from the doctor or synchronous methodologies such as video calls should the need arise, and the applicable standard of care is being met by this telehealth methodology.

• 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 prior to proceeding further with this attestation.

Consent to Telehealth

• understand and acknowledge that this is telehealth model is a supplemental mode of care 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 interactions with my primary provider.

• understand and acknowledge that due to the nature telehealth, the Telehealth Provider is not able to: (1) monitor my ongoing health or lab values for side effects or efficacy, (2) observe how I tolerate any prescribed treatment, or (3) determine if the prescribed treatment is working as intended. 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 patient- doctor relationship, am providing informed consent to use this telemedicine technology, and I am being directed by the Telehealth Provider to consult my primary provider immediately after beginning any treatment prescribed by the Telehealth Provider for follow up or to address any adverse reactions because the patient-doctor relationship created by this telehealth encounter terminates at the end of this virtual visit (and/or receipt of the prescription, if appropriate).

• 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.

• hold TelyRx and the Telehealth Provider harmless clause 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, including HIPAA.

Clinical Information About Me Specific To The Drug I Am Requesting

Oseltamivir:

• understand that it is used to treat or prevent the flu if there is a known exposure within 48 hours
• have not had a hypersensitivity reaction to oseltamivir or any component of the formulation

Azithromycin:

• have not had a hypersensitivity reaction to azithromycin, erythromycin, other macrolides, or any component of the formulation
• do not have a history of cholestatic jaundice or hepatic dysfunction associated with previous use of azithromycin
• do not have a diagnosis of Myasthenia gravis
• understand this medication may interact with medications being metabolized similarly, including phenobarbital, phenytoin, rifampin, and St. John’s Wort will use the medication as prescribed for the appropriate treatment and duration
• understand this medication is associated with altered cardiac conduction including prolonged QT interval and ventricular tachycardia, increased risk for Clostridioides difficile (C. diff) infection, liver injury, immediate and delayed hypersensitivity reactions, and hearing loss

Lidocaine Viscous Solution:

• have not had a hypersensitivity reaction to lidocaine, other local anesthetics, or any component of the formulation
• do not have a bacterial infection at the site of the application, tuberculous or fungal lesions of the skin or viral infections including vaccinia, varicella, and acute herpes simplex
• do not have a history of familial malignant hyperthermia
  do not have bleeding disorders or heart block
• am using this medication for mouth and throat pain or sores
• will not swallow this medication or eat for 60 minutes after using due to trisk of imparired swallowing and/or aspiration
• understand that ingestion of this medication can result in rare but serious side effects including acidosis, methemoglobinemia, seizure, and trouble breathing
• will discontinue the use of this product if local sensitivity or infection occurs

Ibuprofen:

• have not had a hypersensitivity reaction to ibuprofen, other non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. aspirin, naproxen, celecoxib) or any component of the formulation 
• have not had coronary artery bypass surgery (CABG) 
• do not have phenylketonuria (PKU) 
• understand ibuprofen and other NSAIDs can increase the risk of events such as heart attack (myocardial infarction), stroke, and worsen high blood pressure and heart failure 
• understand ibuprofen increases bleeding time and increases the risk of hemorrhage  
• understand this medication increases the risk of liver and kidney injury 
• understand ibuprofen and other NSAIDs can increase the risk of gastrointestinal events such as ulcers, bleeding, or fatal damage to the stomach or intestines. These events may be more severe in individuals 65 years and older. I will discontinue this medication if experiencing reoccurring stomach pain or other serious medical problems while taking this medication. 
• understand this medication may interact with medications being metabolized similarly, including lithium, warfarin, methotrexate, and blood pressure medications 
• understand this medication may increase the risk of aseptic meningitis 

Methylprednisolone:

• Have not had a hypersensitivity reaction to methylprednisolone, other corticosteroids (e.g. prednisone) or any component of its formulation
• Do not have a systemic fungal infection or sepsis
• Am taking this medication as indicated for inflammation for the intended duration of 6 days
• I understand that long-term use of methylprednisolone at immunosuppressive doses could result in adrenal suppression, Cushing syndrome (fluid retention, weight gain), risk for infections (including Pneumocystis jirovecii pneumonia, herpes zoster, and tuberculosis), osteoporosis, and delayed wound healing
• Do not have a history of heart failure or myocardial infarction (heart attack) and I understand methylprednisolone can worsen high blood pressure and heart failure
• Do not have a history of seizure disorder
• Do not have a history of optic neuritis or ocular herpes simplex
• Do not have myasthenia gravis, osteoporosis, or systemic sclerosis
• Do not have any of the following GI diseases: diverticulitis, fresh intestinal anastomoses, peptic ulcer disease, ulcerative colitis, abscess or other pyogenic (pus-producing) infections
• Understand methylprednisolone may cause high blood sugar (hyperglycemia) in patients with and without a history of diabetes and certain conditions may increase risk (e.g., transplant, cancer and chronic rheumatologic conditions)
• Understand that older adults are more susceptible to behavioral side effects (e.g., confusion, hallucinations, mania, agitation, depression, anxiety)

Ondansetron ODT:

• have not had a hypersensitivity reaction to ondansetron or any component of the formulation 
• am not taking apomorphine 
• do not have phenylketonuria (PKU) 
• understand this medication increases the risk of serotonin syndrome when taken with other serotonergic drugs including other SSRIs (e.g. citalopram, fluoxetine, paroxetine, sertraline, fluvoxamine), SNRIs (e.g. venlafaxine, duloxetine, desvenlafaxine), St. John’s Wort, or MDMA/”ecstasy” 
• understand this medication can increase ECG intervals and cause bradycardia 

Albuterol Inhaler:

• have not had a hypersensitivity reaction to albuterol or any component of the formulation
• have a diagnosis of asthma or exercise-induced asthma
• understand this medication may exacerbate symptoms in patients associated with the following conditions of cardiovascular disease, diabetes, glaucoma, hyperthyroidism, hypokalemia, and seizure disorder
• understand this medication may cause increase the risk of increased heart rate, arrhythmia, and cardiomyopathy, and other cardiovascular effects
• understand this medication may affect the nervous system causing increased excitement, nervousness, tremor, anxiety, and insomnia

Benzonatate:

• Have not had a hypersensitivity reaction to benzonatate, related compounds, topical numbing medicines or any component of its formulation
• Am using this product as indicated for symptomatic relief of coughing
• Do not have mucus or phlegm with cough and understand by suppressing cough, it may be more difficult to clear mucus from the lungs and airways
• Understand capsules must be swallowed whole and should be avoided in individuals who have an impaired gag reflex or otherwise unable to swallow the capsules whole
• Understand if capsules are broken in the mouth, they may cause numbness in the mouth/throat that could lead to choking or a severe allergic reaction. Refrain from eating or drinking until numbness resolves.

Additional Representations Concerning My Clinical History and Physical Information

• am generally in good health apart from the condition(s) I am seeking medicine(s) for and am not in immediate distress.

• am not pregnant or breastfeeding.

• agree that this attestation accurately discloses my complete medical and medication history in a manner that will allow the prescribing Telehealth Provider to make a valid prescribing decision and therefore agree that all medical information relevant to this telehealth encounter that I would share in an in-person visit or using synchronous technology is encompassed in or covered by the representations contained in this attestation and if afforded the opportunity to provide additional information, I would have no additional relevant information to provide but that the Telehealth Provider nevertheless may ask me follow-up questions or obtain further history, including via video means, if doing so is required for the Telehealth Provider to collect adequate information to make a prescribing decision.

General Information About Prescription Drugs

• understand and acknowledge this attestation does not contain an exhaustive list of precautions, risks, side effects, or details about taking this medication. More information can be obtained at www.fda.gov and I accept the risk that taking this medication may cause one or more of the side effects found 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 I may be taking unless they were also dispensed by TelyRx

• understand and acknowledge that I can find more information regarding the way the medication I am seeking interacts with other drugs at www.drugs.com/drug_interactions.html

• understand and acknowledge that I should consult additional resources, the information provided with the prescription, and/or ask my primary healthcare provider if I have additional questions concerning potential interactions, precautions, risks, side effects, or details about taking this medication prior to taking the medication

Pharmacy Information

• understand and acknowledge that TelyRx 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 primary provider.

• understand and consent to receiving pertinent patient education information regarding the medication I may be prescribed by via electronic means and receive information about refills, if any, via electronic means.

• understand and acknowledge that I am responsible for reviewing the information contained in this attestation thoroughly and contacting the Telehealth Provider or my primary provider if I have additional questions or concerns prior to taking any medicine I may be prescribed using TelyRx.com.

Seek Help in Case of Emergency

• understand and acknowledge that neither TelyRx nor the Telehealth Provider can provide me with emergency care or crisis intervention. In the event of an emergency, I understand that I should immediately contact 911 or go to the nearest emergency room.