Folic Acid

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 folic acid deficiency

• understand that this medication is not appropriate for monotherapy with pernicious, aplastic, or normocytic anemias when anemia is present with vitamin B12 deficiency

• have been previously prescribed folic acid tablets for the treatment of folic acid deficiency by an authorized healthcare provider

• have had my vitamin B12 levels checked to rule out deficiency before starting folic acid therapy

• understand the importance of regular monitoring of my blood levels to ensure effective treatment of folic acid deficiency

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

• do not have pernicious anemia or other vitamin B12 deficiency without concurrent vitamin B12 treatment

• understand that doses greater than 0.1 mg/day may obscure pernicious anemia with continuing irreversible nerve damage progression

• am not taking any medications that may interact with folic acid, including fluorouracil products, fosphenytoin-phenytoin, phenobarbital, primidone, pyrimethamine, raltitrexed, sulfadoxine, sulfasalazine, and green tea

• understand that folic acid may enhance the adverse/toxic effect of fluorouracil products and may diminish the diagnostic effect of pafolacianine

• 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