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 fluticasone, salmeterol, or any component of the formulation
• have not had a severe hypersensitivity reaction to milk proteins or lactose
• will not use as the primary treatment of status asthmaticus or other acute episodes of asthma or chronic obstructive pulmonary disease (COPD)
• will not start fluticasone/salmeterol in significantly worsening or acutely deteriorating COPD
• have already been using fluticasone/salmeterol oral inhalation as prescribed by a pulmonologist or an authorized healthcare provider
• am not pregnant or breastfeeding
• do not have moderate or severe hepatic impairment
• will use the medication as prescribed for the appropriate treatment and duration
• understand fluticasone/salmeterol oral inhalation is used for asthma maintenance and not to treat an asthma attack
• understand inhaled fluticasone/salmeterol products such as Advair Diskus or Wixela Inhub may contain lactose; very rare anaphylactic reactions have been reported in patients with severe milk protein allergy
• will not take nor intend to take the following medications concurrently with fluticasone/salmeterol oral inhalation: long-acting beta-2 agonists, nonselective beta-blockers, cobicistat, topical cocaine, desmopressin, fexinidazole, systemic fusidic acid, kratom, linezolid, loxapine, methacholine, monoamine oxidase inhibitors, nirmatrelvir and ritonavir, tipranavir, or tricyclic antidepressants. I understand this list is not all-inclusive.
• Will not nor intend to take strong CYP3A4 inhibitors with fluticasone/salmeterol oral inhalation such as clarithromycin, erythromycin, diltiazem, amiodarone, itraconazole, verapamil, ritonavir, ketoconazole, or cobicistat. I understand this list is not all-inclusive.
• Understand I can find more information regarding drug-drug interactions at https://www.drugs.com/drug_interactions.html
• Understand to discontinue fluticasone/salmeterol oral inhalation if paradoxical bronchospasm occurs
• Understand prolonged use of corticosteroids, such as the fluticasone contained in fluticasone/salmeterol, may increase incidence of secondary infection, mask acute infection (including fungal infections), prolong or exacerbate viral infections, or limit response to vaccines
• Understand to avoid use of fluticasone/salmeterol oral inhalation, if possible, in patients with ocular herpes, tuberculosis, or viral, fungal, or bacterial or parasitic systemic infections
• Understand local oropharyngeal Candida infections have been reported with the use of fluticasone/salmeterol oral inhalation
• Understand long-term use of inhaled corticosteroids such as fluticasone in fluticasone/salmeterol have been associated with decreases in bone mineral density
• Understand fluticasone/salmeterol is to be used with caution in cardiovascular disease as salmeterol may cause elevation in blood pressure, heart rate, increase risk of arrhythmia, or cause ECG changes
• Understand fluticasone/salmeterol is to be used with caution in diabetes as salmeterol may increase serum glucose and aggravate preexisting diabetes and ketoacidosis
• Understand fluticasone/salmeterol should be used with caution in patients with cataracts and/or glaucoma; prolonged fluticasone use has been associated with increased intraocular pressure, open-angle glaucoma, and cataracts
• Understand fluticasone/salmeterol should be used with caution in seizure disorders as salmeterol may result in CNS stimulation/excitation
• Understand inhaled corticosteroids such as the fluticasone in fluticasone/salmeterol have been associated with increased risk of pneumonia
• Understand fluticasone, contained in fluticasone/salmeterol, may cause hypercortisolism or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children or in patients receiving high doses for prolonged periods. HPA axis suppression may lead to adrenal crisis.
• Understand withdrawal and discontinuation of a corticosteroid such fluticasone in fluticasone/salmeterol should be done slowly and carefully
• 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

• understand that TelyRx LLC does not provide medical care and the providers who use TelyRx to provide telehealth services (“Telehealth Providers”) should not replace your primary provider.
• understand that the Telehealth Providers are not able to: (1) monitor ongoing health or lab values for side effects or efficacy, (2) observe how you (or your pet) tolerate any prescribed treatment, or (3) determine if the prescribed treatment is working as intended and 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 Providers.
• understand that by using this site, I have created a patient-client-doctor relationship and I am being directed by the Telehealth Providers to consult my primary provider soon after beginning any treatment prescribed by the Telehealth Providers.
• understand that this is a supplemental mode of care for your convenience and the Telehealth Providers are not to be used, or relied on, as a replacement for in-person follow-up visits or interactions with your primary provider.