Omeprazole - Sodium Bicarbonate Packet

I agree, in the form of a declaration, given under oath and penalty of perjury, that I:

General Information

• am 18 years or older and am completing this attestation for myself, doing so voluntarily, and have provided accurate demographic information including, but not limited to my valid name, address, IP address, and location I am visiting this website from, along with accurately reporting my sex assigned at birth, height, and weight.

• will only use this service to seek a prescription for myself, will use it as prescribed, and will not provide any prescription medicine I receive to any other person.

• understand that this attestation under oath will be reviewed and relied on by a doctor licensed in my state (the “Telehealth Provider”) and that the name of the Telehealth Provider who will be responsible for reviewing my attestation and making a prescribing decision, along with his or her credentials, was available to me and I reviewed it by visiting the Consent to Telehealth page on the TelyRx.com website before completing this attestation.

• understand that prescribing medications via telemedicine, as is the case during in-person care, is at the professional discretion of the physician. The indication, appropriateness, and safety considerations for each prescription issued during this telemedicine encounter, and the number of refills, if any, will be evaluated by the Telehealth Provider in accordance with state and federal laws, as well as current standards of practice in your state.

• agree a valid physician-patient relationship is being established via this asynchronous telemedicine technology, that the virtual visit may be supplemented by additional questions from the doctor or synchronous methodologies such as video calls should the need arise, and the applicable standard of care is being met by this telehealth methodology.

• understand and acknowledge that I am responsible for reviewing the terms and conditions relevant to this telehealth encounter located at: https://telyrx.com/terms-conditions prior to proceeding further with this attestation.

Consent to Telehealth

• am using this medication as indicated for the treatment of gastroesophageal reflux disease (GERD)

• have been previously prescribed omeprazole and sodium bicarbonate sachets for the treatment of GERD by an authorized healthcare provider

• have not had a hypersensitivity reaction to omeprazole, sodium bicarbonate, other substituted benzimidazole proton pump inhibitors, or any component of the formulation

• understand that this medication should be taken 30 to 60 minutes before a meal, preferably before breakfast

• am aware that the safety and effectiveness of this medication in combination with other antisecretory agents have not been established

• am aware of the need to have my magnesium levels checked at baseline and periodically thereafter, especially if taking concomitant digoxin, diuretics, or other drugs known to cause hypomagnesemia

• am aware of the need to have my calcium levels checked at baseline and periodically thereafter, as recommended by my healthcare provider

• do not have a history of acid-base balance disorders, Bartter's syndrome, hypocalcemia, or hypokalemia

• understand the risk of Clostridioides difficile-associated diarrhea (CDAD) and to seek medical attention if persistent diarrhea occurs

• understand the risk of severe cutaneous adverse reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, and to discontinue use if symptoms such as red, swollen, blistered, or peeling skin occur

• understand the risk of bone fractures with long-term use and have discussed with my healthcare provider about the duration of therapy and the need for calcium and vitamin D supplementation

• understand the risk of vitamin B12 deficiency with prolonged use and to monitor for symptoms such as tiredness, mood changes, or numbness

• understand the risk of hypomagnesemia with prolonged use, which may lead to serious conditions such as tetany, seizures, and cardiac arrhythmias, and to report symptoms such as muscle cramps or seizures to my healthcare provider

• understand the potential for drug interactions, especially with clopidogrel, and to inform my healthcare provider of all medications I am taking

• am not taking rilpivirine-containing products

• am not taking clopidogrel

• am not taking any medications that may decrease the serum concentration of omeprazole, such as St John's Wort or strong CYP2C19 inducers

• am not taking any medications that may increase the serum concentration of omeprazole, such as strong CYP2C19 inhibitors

• am aware that this medication contains sodium bicarbonate and to use it with caution if I am on a sodium-restricted diet

• am aware to not use this medication for more than 14 days or more often than every 4 months unless directed by a physician

Clinical Information About Me Specific To The Drug I Am Requesting

• am using this medication as indicated for the treatment of acne vulgaris

• have been previously prescribed and used clindamycin topical gel for the treatment of acne as directed by an authorized healthcare provider

• have not had a hypersensitivity reaction to clindamycin, lincomycin, or any component of the formulation

• am aware of the need to use this medication in combination with benzoyl peroxide to reduce the risk of antibiotic resistance

• am aware of the potential for Clostridioides difficile-associated diarrhea (CDAD) and to monitor for symptoms such as significant diarrhea, abdominal cramps, or passage of blood and mucus

• am aware to avoid contact with eyes, mouth, lips, mucous membranes, or broken skin when applying the topical gel

• do not have a history of regional enteritis, ulcerative colitis, or antibiotic-associated colitis

• understand the use of clindamycin may result in fungal or bacterial superinfection, including Clostridioides difficile-associated diarrhea (CDAD), and to discontinue use and consult a healthcare provider if significant diarrhea, abdominal cramps, or passage of blood and mucus occurs

Additional Representations Concerning My Clinical History and Physical Information

• am generally in good health apart from the condition(s) I am seeking medicine(s) for and am not in immediate distress.

• am not pregnant or breastfeeding.

• agree that this attestation accurately discloses my complete medical and medication history in a manner that will allow the prescribing Telehealth Provider to make a valid prescribing decision and therefore agree that all medical information relevant to this telehealth encounter that I would share in an in-person visit or using synchronous technology is encompassed in or covered by the representations contained in this attestation and if afforded the opportunity to provide additional information, I would have no additional relevant information to provide but that the Telehealth Provider nevertheless may ask me follow-up questions or obtain further history, including via video means, if doing so is required for the Telehealth Provider to collect adequate information to make a prescribing decision.

General Information About Prescription Drugs

• understand and acknowledge this attestation does not contain an exhaustive list of precautions, risks, side effects, or details about taking this medication. More information can be obtained at www.fda.gov and I accept the risk that taking this medication may cause one or more of the side effects found at www.fda.gov

• understand and acknowledge that only major drug interactions are listed in this attestation and interactions have not been reviewed against the other medications, supplements, or herbal products I may be taking unless they were also dispensed by TelyRx

• understand and acknowledge that I can find more information regarding the way the medication I am seeking interacts with other drugs at www.drugs.com/drug_interactions.html

• understand and acknowledge that I should consult additional resources, the information provided with the prescription, and/or ask my primary healthcare provider if I have additional questions concerning potential interactions, precautions, risks, side effects, or details about taking this medication prior to taking the medication

Pharmacy Information

• understand and acknowledge that TelyRx is a licensed pharmacy, does not provide medical care or medical advice, and the independent Telehealth Provider who uses TelyRx.com to provide telehealth services acts separately from and is not employed by TelyRx and should not replace your primary provider.

• understand and consent to receiving pertinent patient education information regarding the medication I may be prescribed by via electronic means and receive information about refills, if any, via electronic means.

• understand and acknowledge that I am responsible for reviewing the information contained in this attestation thoroughly and contacting the Telehealth Provider or my primary provider if I have additional questions or concerns prior to taking any medicine I may be prescribed using TelyRx.com.

Seek Help in Case of Emergency

• understand and acknowledge that neither TelyRx nor the Telehealth Provider can provide me with 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.