Zafemy

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 this medication as indicated for contraception

• have been previously prescribed Zafemy for contraception by an authorized healthcare provider

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

• have a BMI <30 kg/m2

• am aware that the patch may be less effective in patients weighing ≥90 kg

• understand that this medication is contraindicated in women over 35 years of age who smoke

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

• am aware of the increased risk of venous thromboembolism and to monitor for any signs or symptoms

• understand the importance of applying the patch correctly and consistently to ensure efficacy

• am aware of the need to use an additional method of contraception if the patch becomes detached for more than 24 hours

• 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/paritaprevir/ritonavir with or without dasabuvir

• am not at high risk of arterial or venous thromboembolic events, including cerebrovascular disease, coronary artery disease, diabetes mellitus with vascular disease, deep vein thrombophlebitis or pulmonary embolism, hypercoagulopathies, uncontrolled hypertension, headaches with focal neurological conditions, migraine headaches with aura or if over 35 years of age, thrombogenic valvular or rhythm diseases of the heart

• do not smoke cigarettes if over 35 years of age

• understand this medication is contraindicated in patients with a history of breast cancer, hepatic tumors, or hepatic disease

• understand this medication may cause irregular bleeding, amenorrhea, or spotting, especially during the first 3 months of therapy

• understand this medication may increase the risk of cervical cancer, hepatic adenomas, or carcinomas with long-term use

• understand this medication may cause chloasma, especially with sun exposure

• understand this medication may adversely affect lipid levels, including serum triglycerides

• understand this medication may increase the risk of thromboembolic disorders, especially in patients with inherited thrombophilias, age >35 years, hypertension, obesity, or tobacco use

• understand this medication may impair glucose tolerance and should be used with caution in patients with diabetes or prediabetes

• understand this medication may cause gallbladder disease or worsen existing gallbladder disease

• understand this medication may exacerbate symptoms in patients with hereditary angioedema

• understand this medication may increase the risk of hypertension, especially with age, dose, and duration of use

• understand this medication may cause depression or mood changes

• understand this medication may cause retinal thrombosis, and I should discontinue use if I experience unexplained vision changes

• understand this medication may cause hepatic impairment and should be discontinued if jaundice develops

• understand this medication may cause fluid retention, weight gain, or breast changes

• understand this medication may cause application-site reactions, including irritation or rash

• am not currently taking any medications that are known to interact with hormonal contraceptives, such as certain anti-seizure medications, antibiotics, or HIV medications

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.