Tri-Sprintec

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

• understand and acknowledge that this telehealth model is a supplemental mode of care for my convenience and the Telehealth Provider is not to be used, or relied on, as a replacement for in-person follow-up visits or interactions with my primary provider.

• understand and acknowledge that due to the nature of telehealth, the Telehealth Provider is not able to: (1) monitor my ongoing health or lab values for side effects or efficacy, (2) observe how I tolerate any prescribed treatment, or (3) determine if the prescribed treatment is working as intended. I am aware of these limitations and nevertheless assume any risks associated with this modality of care and waive any claim I may have in the future against TelyRx and/or the Telehealth Provider.

• understand and acknowledge that by using TelyRx and providing this attestation to the Telehealth Provider, I have created a patient- doctor relationship, am providing informed consent to use this telemedicine technology, and I am being directed by the Telehealth Provider to consult my primary provider immediately after beginning any treatment prescribed by the Telehealth Provider for follow up or to address any adverse reactions because the patient-doctor relationship created by this telehealth encounter terminates at the end of this virtual visit (and/or receipt of the prescription, if appropriate).

• agree that the Telehealth Provider determines, in conjunction with applicable laws, whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter.

• understand that TelyRx takes appropriate security measures in conjunction with the use of this telemedicine technology, such as encrypting data, enabling password protection of data files, and/or utilizing other reliable authentication techniques, but recognize there remain potential risks to privacy notwithstanding such measures.

• hold TelyRx and the Telehealth Provider harmless clause for information lost due to technical failures and provide my express consent for TelyRx and the Telehealth Provider to transmit patient-identifiable information to associates in order to provide the services sought, if done so consistent with state and federal law, including HIPAA.

Clinical Information About Me Specific To The Drug I Am Requesting

• am using Tri-Sprintec as indicated for contraception and/or treatment of moderate to severe acne vulgaris

• have been previously prescribed Tri-Sprintec for contraception or acne vulgaris by an authorized healthcare provider

• have not had a hypersensitivity reaction to ethinyl estradiol, norgestimate, or any component of the formulation

• understand that Tri-Sprintec is contraindicated in women over 35 years of age who smoke due to increased risk of serious cardiovascular events

• am aware of the need to use an additional method of contraception if I miss doses or start the medication more than 5 days after the onset of menses

• have had my blood pressure checked within the past 12 months and it is within normal range

• am aware of the need to monitor for signs of thromboembolic disorders, such as swelling, warmth, numbness, or pain in a leg or arm

• understand the importance of monitoring for any changes in vision or signs of retinal thrombosis

• am aware of the need to monitor for any signs of depression or mood changes

• understand the importance of regular check-ups to assess for any potential health status changes, including weight and blood pressure

• do not have a current or history of breast cancer or any other hormone-sensitive cancer

• do not have hepatic tumors or hepatic disease

• do not have undiagnosed abnormal uterine bleeding

• am not using hepatitis C drug combinations containing ombitasvir/ritonavir, with or without dasabuvir

• do not have a history of cerebrovascular disease, coronary artery disease, or diabetes mellitus with vascular disease

• do not have a history of deep vein thrombosis, pulmonary embolism, or any other thromboembolic disorder

• do not have hypercoagulopathies

• do not have uncontrolled hypertension

• do not have headaches with focal neurological symptoms

• do not have migraine headaches with aura or migraine headaches if over 35 years of age

• do not have thrombogenic valvular or rhythm diseases of the heart

• am not over 35 years of age and smoke

• do not smoke cigarettes or use tobacco products while taking Tri-Sprintec due to increased risk of serious cardiovascular events

• understand that this medication does not protect against HIV infection or other sexually transmitted diseases

• understand this medication may cause blood clots, including deep vein thrombosis and pulmonary embolism

• understand this medication may cause liver problems, including hepatic adenomas or carcinomas

• understand this medication may cause high blood pressure and I should have my blood pressure monitored regularly

• understand this medication may cause mood changes, including depression

• understand this medication may cause gallbladder problems, including pain in the upper right belly area or between the shoulder blades

• understand this medication may cause vision changes, including loss of eyesight or changes in how contact lenses feel

• understand the importance of taking the medication at the same time each day

• understand the need to use an additional method of contraception if I miss two or more active tablets in a row

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.