Esomeprazole

I agree, under oath and penalty of perjury, that I:

• Am 18 years or older

• am using this medication as indicated for the treatment of gastroesophageal reflux disease (GERD)

• understand that this medication should be taken at least 1 hour before meals, preferably before breakfast and the capsule should be swallowed whole and not chewed or crushed

• have been previously prescribed esomeprazole for the treatment of GERD by an authorized healthcare provider

• have my magnesium levels checked periodically while taking esomeprazole

• will monitor for any signs of C. difficile-associated diarrhea and seek medical attention if symptoms occur

• do not have a hypersensitivity to esomeprazole, other substituted benzimidazole proton pump inhibitors, or any component of the formulation (more information can be found at www.fda.gov)

• am not taking rilpivirine, St John's Wort, clopidogrel, nelfinavir, pazopanib, pexidartinib, selpercatinib, sotorasib, or sparsentan

• understand the risk of C. difficile infection, pneumonia, GI malignancies, and bone loss/fractures with long-term use, especially in patients 65 years and older

• understand that long-term use may lead to vitamin B12 deficiency, hypomagnesemia, and bone fractures and will discuss with my healthcare provider if I am at risk

• understand that esomeprazole may cause cutaneous lupus erythematosus and systemic lupus erythematosus

• understand that esomeprazole may cause acute interstitial nephritis

• understand that esomeprazole may cause fundic gland polyps with long-term use

• do not have a history of gastric malignancy

• understand this is not a comprehensive list of precautions, risks, side effects, or details about taking this medication

• understand that only major drug interactions are listed and have not been reviewed against the other medications, supplements, or herbal products I may be taking unless also filled by TelyRx

• acknowledge that TelyRx services do not include 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.

• understand and accept that pertinent patient information regarding the medication will be sent to me via electronic means

• understand and acknowledge that I am responsible for viewing the terms and conditions which can be found at: https://telyrx.com/terms-conditions