By clicking the “I Agree” button below, you certify under penalty of perjury that the following statements are true and correct and understand that a medical provider will rely on the truthfulness of your statements when determining whether a prescription is warranted and appropriate.

I agree that I:

• am between the ages of 18 and 65 years
• have not had a hypersensitivity or idiosyncratic reaction to promethazine, other phenothiazines, or any component of the formulation
• Am not in a comatose state nor intend on administering to a patient in a comatose state
• Am not taking promethazine for the treatment of lower respiratory tract symptoms including asthma
• Am not going to use in children less than 2 years of age
• Am not going to administer inter-arterially or subcutaneously or administer intravenously at concentrations greater than 1 mg/ml
• have already been using promethazine as prescribed by an authorized healthcare provider
• am not pregnant or breastfeeding
• Do not have liver disease or impairment
• Understand promethazine should not be used in pediatric patients younger than 2 years of age because of the potential for fatal respiratory depression
• Understand promethazine can cause severe chemical irritation and tissue damage when administered as an injection
• Understand promethazine is listed in the Beers Criteria as a potentially inappropriate medication to be avoided in patients 65 years and older (independent of diagnosis or condition) due to its potent anticholinergic properties resulting in increased risk of confusion, dry mouth, constipation, and other toxicities.
• Understand the use of promethazine may aggravate the following medical conditions and should be used with caution: bone marrow suppression, cardiovascular disease, GI motility, glaucoma, hepatic impairment, myasthenia gravis, Parkinson disease, conditions of compromised respiratory function such COPD or sleep apnea, urinary retention, benign prostatic hyperplasia (BPH), or bladder neck obstruction
• Understand promethazine may cause anticholinergic adverse effects such as blurred vision, confusion, constipation, dry eye, urinary retention, and dry mouth
• Understand promethazine has been associated with dizziness, drowsiness, delirium, motor dysfunction (motor sensory instability), and sedated state in adult and pediatric patients
• Understand extrapyramidal reactions (EPS), including akathisia (i.e., inability to remain still), acute dystonia, drug-induced parkinsonism, and tardive dyskinesia, have occurred with the use of promethazine in adult and pediatric patients
• Understand promethazine may cause orthostatic hypotension which may increase the risk for falls in older patients; this risk may be augmented by the sedative effects of promethazine
• Understand promethazine may intensify, increase, or prolong the sedative action of other CNS depressants, such as tricyclic antidepressants, sedatives/hypnotics, narcotics, narcotic analgesics, alcohol, general anesthetics, and tranquilizers; therefore, those medicines should be avoided when taking promethazine
• Will not take nor intend to take the following concurrently with promethazine: aclidinium, aminolevulinic acid, nasal azelastine, blonanserin, bromopride, bromperidol, buprenorphine, chlormethiazole, cimetropium, clozapine, daridorexant, dexmedetomidine, droperidol, eluxadoline, epinephrine, flunarizine, flunitrazepam, glycopyrrolate oral inhalation, glycopyrronium topical, hydroxyzine, ipratropium oral inhalation, kratom, lemborexant, levosulpiride, loxapine, methotrimeprazine, metoclopramide, nabilone, nasal olopatadine, opioid agonists, orphenadrine, oxatomide, oxomemazine, oxybate salt products, oxycodone, paraldehyde, pitolisant, potassium chloride, potassium citrate, pramlintide, revefenacin, rivastigmine, ropeginterferon alfa-2b, secretin, suvorexant, thalidomide, tiotropium, tranylcypromine, umeclidinium, zolpidem, zuranolone
• understand this is not a comprehensive list of severe or major drug interactions and I can find more information regarding drug-drug interactions at https://www.drugs.com/drug_interactions.html
• Understand there is a black box warning in which severe chemical irritation and damage to tissues has been reported, regardless of parenteral route of administration, of promethazine injection including gangrene, tissue necrosis, and thrombophlebitis
• 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