Ethinyl Estradiol & Etonogestrel Vaginal Ring

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, including anaphylaxis or angioedema, to ethinyl estradiol, etonogestrel, or any component of the formulation
• do not have current, nor history of, breast cancer
• do not have hepatic impairment or hepatic disease or hepatic tumors (benign or malignant)
• do not have undiagnosed abnormal uterine bleeding
• am not pregnant or breastfeeding
• understand the Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs (contraindicated in pregnancy) which have a heightened risk of causing significant patient harm when used in error
• will not nor intend to take concurrently with hepatitis C drug combinations containing  ombitasvir, paritaprevir, ritonavir,  with or without dasabuvir
• understand NuvaRing is for use in patients who may become pregnant; not for use prior to menarche or postmenopause
• do not have arterial or venous thrombotic diseases including cerebrovascular disease, coronary artery disease, diabetes mellitus with vascular disease
• do not have current or history of deep venous thrombosis (DVT) or pulmonary embolism (PE)
• do not have headaches with focal neurological symptoms
• do not have migraine headaches with aura or migraine headaches if >35 years of age
• do not have uncontrolled high blood pressure
• do not have thrombogenic valvular or rhythm diseases of the heart (eg, subacute bacterial endocarditis with valvular disease, atrial fibrillation)
• do not smoke if age >35 years
• do not have inherited or acquired hypercoagulopathies
• understand there is a US Boxed Warning in which cigarette smoking increases the risk of serious cardiovascular events from combination hormonal contraceptive (CHC) use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, CHCs, including ethinyl estradiol/etonogestrel, should not be used by women who are over 35 years of age and smoke.
• understand the use of combination hormonal contraceptives has been associated with a slight increased risk of cervical cancer
• understand combination hormonal contraceptives may adversely affect lipid levels, including serum triglycerides
• understand this medication may worsen other disease states or conditions including angioedema, bariatric surgery, breast cancer, cardiovascular disease, depression, diabetes, endometrial cancer, gallbladder disease, hepatic impairment, hepatitis, hypertension, migraine, ovarian cancer, solid organ transplant, systemic lupus erythematosus
• understand combination hormonal contraceptives do not protect against HIV infection or other sexually transmitted diseases
• understand that due to the increased risk of venous thromboembolism (VTE) postpartum, combination hormonal contraceptives are not to be initiated <21 days following delivery
• will not take nor intend to take the following due to severe or major drug-drug interactions: anastrozole, antihepaciviral combination products, aprepitant, asparaginase products, atazanavir, bile acid sequestrants, brigatinib, carfilzomib, cobicistat, cosyntropin, CYP3A4 inducers, dasabuvir, dehydroepiandrosterone, efavirenz, elafibranor, elagolix, encorafenib, exemestane, exenatide, felbamate, ferric maltol, fexinidazole, fezolinetant, fosaprepitant, fostemsavir, systemic fusidic acid, glecaprevir, pibrentasvir, griseofulvin, growth hormone analogs, hemin, indium 111 capromab pendetide, ivosidenib, ixazomib, lamotrigine, lixisenatide,  lomitapide, mavacamten, metyrapone, mifepristone, mitotane,  mobocertinib, mycophenolate,  nirmatrelvir,  ritonavir,  octreotide, olutasidenib, omaveloxolone, ospemifene, oxcarbazepine, perampanel, pexidartinib, pitolisant, protease inhibitors, raloxifene, repotrectinib, sugammadex, taurursodiol, tetrahydrocannabional, cannabidiol, tirzepatide, tizanidine, topiramate, tovorafenib, tranexamic acid, ulipristal, vaborbactam
• Understand I can find more information regarding drug-drug interactions at https://www.drugs.com/drug_interactions.html
• 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