Norgestimate-Ethinyl Estradiol

Estarylla is a combined oral contraceptive of estrogen and progesterone that is used to prevent pregnancy. Pills are contained in a monthly blister card of 3 weeks of active pills and 1 week of placebo pills.

By clicking the “I Agree” button below, you certify under penalty of perjury that the following statements are true and correct and understand that a medical provider will rely on the truthfulness of your statements when determining whether a prescription is warranted and appropriate.

I agree that I:

• am 18 years or older
• have not had a hypersensitivity reaction to any component of the formulation
  
• am not pregnant, have given birth in the past 4 weeks, or have had an abortion or miscarriage in the past 4 weeks
  
• am using this medication for the purpose of contraception
  
• understand the use of this medication and cigarette smoking increases the risk of serious cardiovascular events
  
• am not over the age of 35 years old and smoke cigarettes
  
• understand taking medication with estrogen alone and with progestin therapy increases the risk of cardiac events including heart attack, stroke, pulmonary embolism, and deep vein thrombosis
  
• do not have a history of liver (hepatic) impairment, hepatic tumors, or severe kidney (renal) impairment
  
• do not have current or history of breast cancer
  
• do not have abnormal genital and uterine bleeding
  
• do not have a benign or malignant tumor
  
• do not have systemic lupus erythematosus (SLE)
  
• am not taking hepatitis C drugs containing ombitasvir, ritonavir, and dasabuvir
  
• understand this medication should not be used as daily or regular birth control
  
• understand to take a pregnancy test if regular menstruation is delayed for more than 7 days
  
• have not gone through menopause
  
• understand this medication may interact with medications being metabolized similarly, including phenobarbital, phenytoin, rifampin, and St. John’s Wort
  
• do have a current or history of blood clots, including venous thromboembolism (VTE) or deep vein thrombosis (DVT)
  
• do have a history of arterial or venous thromboembolic disease (e.g. cerebrovascular disease, coronary artery disease, diabetes with vascular disease, uncontrolled high blood pressure)
  
• do not have headache with neurological symptoms
  
• do not have migraine with aura or am over the age of 35 with migraine
  
• do not have an inherited or acquired abnormal blood clotting disease (hypercoagulopathy)
  
• do not have a heart disease involving the heart valves or heart rhythm
  
• have not had bariatric surgery or solid organ transplantation
  
• will discontinue the medication if any of the following occur: migraine, vision loss, or other visual disturbances
  
• understand this medication may increase the risk of or worsen other disease states (e.g. breast cancer, cervical cancer, liver cancer, cholestasis, gallbladder disease, cardiovascular disease, depression, diabetes, kidney dysfunction)
  
• understand oral contraceptives do not protect against HIV and other sexually transmitted diseases
  
• 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