Isosorbide Mononitrate Extended Release

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

• am 18 years or older

• am using this medication as indicated for the prevention of angina pectoris caused by coronary artery disease

• have been prescribed isosorbide mononitrate tablets for the maintenance treatment of chest pain by an authorized healthcare provider

• have my blood pressure and heart rate monitored regularly while taking Isosorbide mononitrate tablets for chest pain maintenance

• understand the importance of adhering to the prescribed dosing schedule to minimize tolerance development

• do not have a hypersensitivity to isosorbide mononitrate, other nitrates or nitrites, or any component of the formulation (more information can be found at www.fda.gov)

• am not using phosphodiesterase type 5 (PDE-5) inhibitors such as sildenafil, tadalafil, or vardenafil, or riociguat

• do not have hypertrophic cardiomyopathy with left ventricular outflow tract obstruction

• do not have a history of acute myocardial infarction or heart failure

• understand this medication may cause CNS depression, impairing physical or mental abilities, and I should avoid activities requiring mental alertness until I know how it affects me

• understand this medication may cause headaches, including migraine or cluster headaches, which may decrease in frequency and intensity with continued use

• understand this medication may cause hypotension or orthostatic hypotension, and paradoxical bradycardia and exacerbation of angina pectoris may also occur

• understand this medication may precipitate or aggravate increased intracranial pressure, especially with IV nitrates

• will not use this medication to treat sudden chest pain as it is not effective for acute anginal episodes

• 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