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

• am 18 years or older

• am using this medication as an adjunct to diet for the treatment of severe hypertriglyceridemia

• have been previously prescribed fenofibric acid DR capsules for the treatment of hypertriglyceridemia by an authorized healthcare provider

• have my lipid profile monitored at baseline and periodically, including HDL-C within a few months of initiation of therapy

• have my liver function tests monitored at baseline and periodically during therapy

• have my kidney function monitored at baseline and periodically, especially if I have kidney impairment or am at increased risk for developing kidney impairment

• am aware of the signs and symptoms of myopathy, myositis, or rhabdomyolysis and will report any muscle pain, tenderness, or weakness, especially if accompanied by malaise or fever, or brown urine to my healthcare provider

• do not have liver or kidney impairment

• do not have a hypersensitivity to fenofibrate, fenofibric acid, or any component of the formulation (more information can be found at www.fda.gov)

• do not have active liver disease, including primary biliary cirrhosis and unexplained, persistent liver function abnormality

• do not have severe renal impairment or end-stage renal disease (ESRD), including those receiving dialysis

• do not have preexisting gallbladder disease

• am not pregnant or breastfeeding

• understand that therapy should be withdrawn if an adequate response is not obtained after 2 to 3 months of therapy at the maximal daily dose

• understand that this medication may cause cholelithiasis and will discontinue if gallstones are found upon gallbladder studies

• understand that this medication may cause pancreatitis, and will monitor for symptoms such as severe abdominal pain, nausea, or vomiting

• understand that this medication may cause severe skin reactions such as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) and will monitor for symptoms such as red, swollen, blistered, or peeling skin; red or irritated eyes; sores in your mouth, throat, nose, eyes, genitals, or any areas of skin; fever; chills; body aches; shortness of breath; or swollen glands

• understand this medication may cause liver injury, including hepatocellular, cholestatic, or mixed hepatitis, and I will discontinue use if I experience symptoms such as dark urine, jaundice, or persistent nausea

• am not taking any medications that may increase the risk of myopathy or rhabdomyolysis, such as statins, colchicine, or cyclosporine, without consulting my healthcare provider

• am not taking any medications that may enhance the photosensitizing effect, such as aminolevulinic acid or methoxsalen, without consulting my healthcare provider

• am not taking any bile acid sequestrants without ensuring proper timing of administration to avoid interaction

• 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