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.

Patient Attestation & Consent

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 & Clinical Eligibility

I confirm that I:

• Am 18 years of age or older.

• Am not pregnant or breastfeeding.

• Have not experienced a hypersensitivity reaction (including anaphylaxis or angioedema) to ethinyl estradiol, etonogestrel, or any component of this medication.

• Do not have a current or prior history of breast cancer, liver disease or tumors, undiagnosed abnormal uterine bleeding, or renal impairment.

• Do not have, and have never had, arterial or venous thrombotic disease, including DVT, PE, stroke, coronary artery disease, or diabetes with vascular disease.

• Do not have migraine with aura, focal neurological symptoms, uncontrolled hypertension, thrombogenic heart conditions, or inherited/acquired hypercoagulable disorders.

• Do not smoke cigarettes if over 35 years of age.

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

Medication-Specific Acknowledgments

I understand that:

• The Ethinyl Estradiol Vaginal Ring is used for contraception, is not for use prior to menarche or after menopause, and does not protect against HIV or other sexually transmitted infections.

• Combination hormonal contraceptives carry an increased risk of blood clots and cardiovascular events, especially in individuals over 35 who smoke.

• This medication should not be started within 21 days postpartum due to increased risk of venous thromboembolism.

• This medication may affect lipid levels, blood pressure, mood, vision, liver function, gallbladder function, and may worsen certain medical conditions.

• I will not take this medication with contraindicated drugs, including certain hepatitis C treatments, CYP3A4 inducers, or other medications with major drug–drug interactions.

• I can review drug interaction details at:
  https://www.drugs.com/drug_interactions.html

• This attestation does not list every possible risk, precaution, or side effect. Additional information is available at www.fda.gov.

Additional Health Representations

I confirm that:

• I am generally in good health and not in immediate distress.

• I have accurately disclosed my complete medical and medication history relevant to this telehealth encounter.

• I understand the Telehealth Provider may request additional information or a follow-up visit (including video) if needed to make a safe prescribing decision.

Pharmacy & Telehealth Disclosures

I understand that:

• ModernFillRx partners with licensed third-party pharmacies to dispense and fulfill prescriptions.

• Only major drug interactions are reviewed unless medications are also dispensed by ModernFillRx.

• I consent to receiving medication education and refill information electronically.

• Telehealth services are provided for convenience and do not replace in-person care with my primary provider.

Emergency Notice

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