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

• Are 18 years of age or older and are completing this attestation voluntarily and for yourself.
• Have provided accurate and complete information, including your legal name, address, IP address, location, sex assigned at birth, height, and weight.
• Will use ModernFillRx only to seek treatment and prescriptions for yourself, will take medications only as prescribed, and will not share prescription medications with others.
• Understand this attestation is made under oath and will be reviewed and relied upon by a licensed physician in your 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 medications via telemedicine, like in-person care, is at the professional discretion of the physician, and that prescribing decisions (including refills) are made in accordance with state and federal laws and current standards of medical practice.
• Agree that a valid physician-patient relationship is established through this asynchronous telemedicine encounter, and that additional questions or live visits (such as video calls) may be required if clinically appropriate.
• Acknowledge that you have reviewed and agree to the Terms & Conditions located at:
  https://modernfillrx.com/terms-conditions

Consent to Telehealth
You understand and acknowledge that:

• Telehealth services are provided for convenience and are not intended to replace follow-up care with your primary healthcare provider.
• Due to the nature of telehealth, the Telehealth Provider cannot:
  1. Monitor your ongoing health or lab values
  2. Observe how you tolerate treatment
  3. Confirm long-term treatment effectiveness
• You accept these limitations and assume the risks associated with telehealth care.
• By using ModernFillRx and submitting this attestation, you 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.
• You agree to consult your primary healthcare provider after beginning treatment or if you experience adverse reactions.
• The Telehealth Provider determines whether your condition is appropriate for telemedicine, in accordance with applicable laws.
• ModernFillRx employs reasonable security measures (including encryption and authentication), but you understand that no system is completely risk-free.
• You consent to the secure transmission of patient-identifiable information to authorized partners as necessary to provide services, in compliance with HIPAA and applicable law.
• You agree to hold ModernFillRx and the Telehealth Provider harmless for information lost due to technical failures beyond their control.

Clinical Information – Norethindrone-Ethinyl Estradiol
You confirm that you:

• • Are using this medication for contraception and/or treatment of moderate to severe acne.
  • Have previously been prescribed norethindrone-ethinyl estradiol by an authorized healthcare provider.
  • Have not experienced an allergic or hypersensitivity reaction to norethindrone, ethinyl estradiol, or any formulation component.
  • Understand this medication should not be used if you are pregnant or breastfeeding within 21 days postpartum.
  • Understand the importance of taking the medication at the same time each day without missing doses.
  • Are aware of the increased risk of serious cardiovascular events, especially if over 35 years of age and smoking.
  • Understand this medication does not protect against HIV or other sexually transmitted infections.
  • Have had your blood pressure checked within the past 12 months and it is within normal range.
  • Do not have a history of thromboembolic disorders, uncontrolled hypertension, estrogen- or progestin-sensitive cancers, liver disease, migraines with aura, or other contraindicated conditions.
  • Are not taking contraindicated medications, including certain hepatitis C drug combinations.
  • Do not smoke cigarettes, particularly if over 35 years of age.
  • Understand the potential risks, including blood clots, liver problems, mood changes, vision changes, and gallbladder issues, and will seek medical care if symptoms occur.
  • Understand the importance of using backup contraception if pills are missed.

Additional Health Representations
You confirm that you:

• Are generally in good health and not in immediate distress.
• Are not pregnant or breastfeeding.
• Have accurately disclosed your complete medical and medication history relevant to this telehealth 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
You acknowledge that:

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

Pharmacy Information
You understand that:

• ModernFillRx partners with licensed third-party pharmacies to dispense and fulfill prescriptions.
• You consent to receiving medication education and refill notifications electronically.
• You are responsible for reviewing all information and contacting your provider with any questions before taking prescribed medication.

Emergency Notice
You understand that:

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