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

• am 18 years or older

• am using this as indicated for short-term and noncontinuous long-term treatment of mild to moderate atopic dermatitis

• understand that this medication is not for continuous long-term use and should be applied only to areas affected by atopic dermatitis

• understand the importance of monitoring for any signs of skin infection, such as oozing, heat, swelling, redness, or pain, and will contact my healthcare provider if these occur

• am aware of the need to monitor for any changes in skin condition, such as new lumps, growths, or changes in moles, and will report these to my healthcare provider immediately

• acknowledge the importance of limiting sun exposure and using protective measures to avoid potential skin damage even when the medication is not on the skin while using pimecrolimus cream

• do not have a hypersensitivity to pimecrolimus or any component of the formulation (more information can be found at www.fda.gov)

• do not have any active bacterial or viral skin infections at the treatment site

• do not have malignant or premalignant skin conditions

• am not immunocompromised or on systemic immunosuppressive therapy

• understand that the safety of intermittent use for more than 1 year has not been established

• understand that there is a potential risk of malignancy, including skin malignancy and lymphoma, with the use of topical calcineurin inhibitors

• understand therapy has been associated with an increased risk of developing eczema herpeticum, varicella zoster, and herpes simplex

• understand pimecrolimus may cause local symptoms (e.g., burning, pruritus, soreness, stinging) during first few days of treatment

• understand pimecrolimus may be associated with development of lymphadenopathy and should be discontinued in patients with unknown cause of lymphadenopathy or acute infectious mononucleosis

• understand skin papilloma (warts) have been observed with use and should be discontinued if there is worsening of skin papillomas or they do not respond to conventional treatment

• 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