1. Eligibility & Safety

• I am not allergic to Hyaluronic Acid, Vitamin C, Tretinoin, Vitamin E, Aloe, or common topical bases (e.g., propylene glycol, alcohols, parabens, fragrance). If I have allergies, I will list them during intake.
• I am not pregnant or breastfeeding, and I will inform my provider if I plan pregnancy.

2. Medical History & Screening

• I will disclose any drug/topical allergies.
• I will list all medications and supplements I take (dose if known).
• I will disclose any medical conditions affecting skin healing/sensitivity (e.g., severe eczema/dermatitis, psoriasis, active rosacea flare, keloid tendency).
• I will state my main goal (e.g., soften lines, even tone, brighten, texture), current concerns & duration, and areas to treat (e.g., face, neck, décolletage).

3. Current Regimen & Procedures

• I will report if I currently use active skincare (e.g., benzoyl peroxide, AHAs/BHAs/glycolic/salicylic acid, vitamin C serums, steroids) or had recent peels/laser/microneedling/waxing (with dates when possible).

4. Use & Precautions

• I will not apply on sunburned skin, open wounds, or broken/irritated skin, and I will avoid use immediately before/after microneedling/procedures without provider guidance.
• I understand Tretinoin increases photosensitivity; I will use daily broad-spectrum SPF 30+, limit UV exposure/tanning, and follow nighttime use as directed.
• I will follow the application order and schedule provided (do not layer incompatible products at the same time unless instructed).
• I will stop use and contact my provider if I experience severe irritation, swelling, blistering, rash, dizziness, or any unexpected reaction.

5. Photos for Clinical Review

• I will upload a clear, well-lit photo of the affected skin area to assist with evaluation and dosing.

6. Identification & Confidentiality

• Uploading a valid government-issued photo ID is a legal requirement to verify my identity before the consultation can be completed.
• This verification complies with state and federal telemedicine regulations.
• My personal information and ID will be handled securely, stored confidentially, and never shared except as required by law or to provide my medical care.

IMPORTANT: Please keep a clear image of your Driver’s License / State ID / Passport (or photo of any government-issued ID) ready on this device to upload.

7. How the Medication is Provided

• I understand this medication may be compounded using USP-grade ingredients by a licensed pharmacy; my instructions (amount/frequency/duration) will be individualized.

8. Consent

• I give my full consent for RightMD INC and its affiliated medical/pharmacy teams to prescribe and dispense this compounded anti-aging cream based on the information I have provided.

9. Payments & Refund Policy

• All purchases and services are final and non-refundable.

10. Policies

• I have read and agree to the Terms & Conditions, Privacy Policy, and Refund & Cancellation Policy.