By clicking the “Agree & Checkout” 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 and that I:

General Information

By using ModernFillRx, I confirm that:

• I am 18 years of age or older, completing this attestation voluntarily for myself, and have provided accurate and truthful information, including my legal name, address, location, IP address, sex assigned at birth, height, and weight.
• I will use ModernFillRx solely to seek treatment and prescriptions for myself, will take medications only as prescribed, and will not share any prescription medication with another person.
• I understand this attestation is made under oath and will be reviewed and relied upon by a licensed physician in my state (“Telehealth Provider”).
• I reviewed the Telehealth Provider’s name and credentials on the Consent to Telehealth page of ModernFillRx.com before completing this attestation.
• I understand that all prescribing decisions are made at the sole professional discretion of the Telehealth Provider, in accordance with applicable state and federal laws and current standards of medical practice.
• I understand that a valid physician-patient relationship is established through this asynchronous telehealth encounter, and that the provider may request additional information or initiate a live (synchronous) visit, such as a video call, if clinically necessary.
• I 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 is provided for convenience and is not intended to replace in-person visits with my primary care provider.
• Due to the nature of telehealth, the Telehealth Provider cannot:
  1. Monitor my ongoing health or lab values
  2. Observe how I tolerate prescribed treatments
  3. Confirm treatment effectiveness over time
• I accept these limitations and assume the risks associated with telehealth care.
• By using ModernFillRx, I provide informed consent to receive care via telemedicine and acknowledge 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 care provider after beginning any prescribed treatment or if I experience side effects or adverse reactions.
• The Telehealth Provider determines whether my condition is appropriate for telemedicine, based on applicable laws and clinical judgment.
• ModernFillRx employs reasonable security safeguards (such as encryption and authentication), but I understand that no system is entirely risk-free.
• I consent to the secure sharing of patient-identifiable information with authorized partners as necessary to provide services, in compliance with HIPAA and applicable laws.
• I agree to hold ModernFillRx and the Telehealth Provider harmless for data loss caused by technical failures beyond their control.

Clinical Information – Medication-Specific (Norethindrone)

I confirm that:

• I am using this medication for contraception and understand the importance of taking it at the same time every day without interruption.
• I have previously been prescribed norethindrone.
• I have not experienced any allergic or hypersensitivity reactions to norethindrone or its ingredients.
• If a dose is missed or taken more than 3 hours late, I understand that I must use backup contraception for 48 hours.
• I understand the importance of confirming I am not pregnant before starting norethindrone.
• I do not have unexplained abnormal genital bleeding, and I will report any abnormal vaginal bleeding to a healthcare provider.
• I understand that norethindrone does not protect against HIV or other sexually transmitted infections.
• I do not have known or suspected breast cancer, liver tumors, or acute liver disease.
• I understand that menstrual irregularities may occur, including spotting, missed periods, or cycle changes.
• I understand that norethindrone may affect cholesterol levels and blood sugar control, and I will use caution if I have hyperlipidemia or diabetes.
• I understand the risk of ectopic pregnancy and will seek medical care if I experience lower abdominal pain.
• I am not taking medications known to reduce norethindrone effectiveness, including CYP3A4 inducers such as rifampin, carbamazepine, or phenytoin.

Important Information About Prescription Medications

I understand 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 here, and interactions with other medications or supplements may not be fully reviewed unless dispensed by ModernFillRx.
• Drug interaction information can also be found at www.drugs.com/drug_interactions.html.
• I should review prescription information and consult my primary provider if I have questions before taking any medication.

Pharmacy Information

I acknowledge that:

• ModernFillRx partners with 3rd party pharmacy to fill rx.
• I consent to receiving medication education, refill information, and notifications electronically.
• I am responsible for reviewing this information and contacting my Telehealth Provider or primary provider with any questions.

Emergency Care 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