Patient Attestation & Consent – Cryselle®

By clicking “Agree & Checkout,” I certify under penalty of perjury that the statements below are true and correct. I understand that a licensed medical provider will rely on the accuracy of my responses when determining whether a prescription is appropriate.

General Information

I confirm that I:

• Am 18 years of age or older and am completing this attestation voluntarily and for myself.
• Have provided accurate and complete information, including my legal name, address, IP address, location, sex assigned at birth, height, and weight.
• Will use this service only to seek treatment and prescriptions for myself, will take any medication only as prescribed, and will not share prescription medication with any other person.
• Understand that this attestation is made under oath and will be reviewed and relied upon by a licensed physician in my state (“Telehealth Provider”).
• Reviewed the Telehealth Provider’s name and credentials on the Consent to Telehealth page of ModernFillRx.com prior to completing this attestation.
• Understand that prescribing medication via telemedicine, as with in-person care, is at the professional discretion of the physician, in accordance with state and federal law and current medical standards.
• Agree that a valid physician-patient relationship is established through this asynchronous telehealth visit, and that additional questions or live visits (such as video calls) may be required if clinically appropriate.
• Acknowledge that I have reviewed and agree to the Terms & Conditions located at:
  https://modernfillrx.com/terms-conditions

Consent to Telehealth

I understand and acknowledge that:

• Telehealth services are provided for convenience and are not intended to replace ongoing or follow-up care with my primary healthcare provider.
• Due to the nature of telehealth, the Telehealth Provider cannot:
  1. Monitor my ongoing health or laboratory values
  2. Observe how I tolerate treatment
  3. Confirm long-term effectiveness of therapy
• I accept these limitations and assume the risks associated with telehealth care.
• By using ModernFillRx, I provide informed consent to telemedicine and understand that the physician-patient relationship ends at the conclusion of this virtual visit and/or issuance of a prescription, if appropriate.
• I agree to follow up with my primary healthcare provider after starting treatment or if I experience side effects or adverse reactions.
• The Telehealth Provider determines whether my condition is appropriate for telemedicine, in accordance with applicable laws.
• ModernFillRx employs reasonable security safeguards, but I understand that no system is completely risk-free.
• I consent to the secure transmission of my health information as necessary to provide services, in compliance with HIPAA and applicable laws.
• I agree to hold ModernFillRx and the Telehealth Provider harmless for information lost due to technical failures beyond their control.

Clinical Information – Cryselle®

I confirm that I:

• Am using Cryselle® for contraception.
• Have previously been prescribed Cryselle® or another combined oral contraceptive by an authorized healthcare provider.
• Have not experienced an allergic or hypersensitivity reaction to norgestrel, ethinyl estradiol, or any component of this medication.
• Understand that Cryselle® is contraindicated in individuals over 35 years of age who smoke due to an increased risk of serious cardiovascular events.
• Understand the importance of taking this medication at the same time every day and using backup contraception if doses are missed.
• Understand that Cryselle® does not protect against HIV or other sexually transmitted infections.
• Have had my blood pressure checked within the past 12 months and it is within normal range.
• Understand the potential risks of blood clots, stroke, heart attack, vision changes, mood changes, and other serious adverse effects, and will seek medical care if symptoms occur.
• Do not have a current or past history of:
  • Breast cancer or hormone-sensitive cancers
  • Liver disease or hepatic tumors
  • Undiagnosed abnormal uterine bleeding
  • Thromboembolic disorders (DVT, PE)
  • Cerebrovascular or coronary artery disease
  • Hypercoagulable conditions
  • Uncontrolled hypertension
  • Migraines with aura or migraines if over age 35
• Am not taking contraindicated medications, including hepatitis C drug combinations containing ombitasvir/ritonavir, with or without dasabuvir.
• Do not smoke or use tobacco products while taking Cryselle®.

Additional Health Representations

I confirm that I:

• Am generally in good health and not in immediate distress.
• Am not pregnant or breastfeeding.
• Have accurately disclosed my complete medical and medication history relevant to this visit.
• Understand the Telehealth Provider may request additional information or follow-up, including via video, if needed to make a safe prescribing decision.

Important Information About Prescription Medications

I acknowledge that:

• This attestation does not include every possible risk, precaution, or side effect.
• Additional information is available at www.fda.gov.
• Only major drug interactions are listed; interactions with supplements or non-ModernFillRx medications may not be fully reviewed.
• Drug interaction details are available at:
  www.drugs.com/drug_interactions.html
• I should consult my primary healthcare provider if I have questions before taking this medication.

Pharmacy Information

I understand that:

• ModernFillRx partners with licensed third-party pharmacies to dispense and fulfill prescriptions.
• I consent to receiving medication education, refill notifications, and related communications electronically.
• I am responsible for reviewing all information and contacting my provider with any questions before taking prescribed medication.

Emergency Notice

I understand that:

• ModernFillRx and its Telehealth Providers do not provide emergency or crisis care.
• In an emergency, I must call 911 or go to the nearest emergency room immediately.