Icosapent Ethyl

I agree that I:

• Am 18 years or older
• Will use this medication for my own personal use and as indicated
• Have not had a hypersensitivity reaction to icosapent ethyl or any component of its formulation (More information about formulation components can be found at www.drugs.com)
• Have a history of hypertriglyceridemia and am currently taking this medication 
• Do not have a history of kidney or liver impairment
• Am not on dialysis
• Understand this medication should be taken with food
• Understand I must maintain standard cholesterol-lowering diet during therapy
• Understand there is a risk of bleeding and that this risk may be increased with concomitant anticoagulant/antiplatelet use
• Do not have a history of known or suspected allergy or sensitivity to fish and/or shellfish
• Do not have a history of atrial fibrillation or flutter
• Am not pregnant or breastfeeding
• Understand and am following up with an authorized healthcare provider to ensure monitoring parameters are completed (triglycerides and lipids monitored at baseline and periodically)
• Will discontinue the medication and seek medical help if I experience any of the following signs or symptoms that may be related to a side effect: fast or abnormal heartbeat, dizziness or passing out, shortness of breath, chest pain, unexplained bruising or bleeding, swelling in the arms or legs, or signs of an allergic reaction
• understand this is not a comprehensive list of precautions, risks, side effects, or details about taking this medication (More information about side effects, precautions and warnings can be found at www.fda.gov)
• understand that 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 I can find more information regarding drug-drug interactions at https://www.drugs.com/drug_interactions.html