1. Eligibility & Safety

• I am not pregnant or breastfeeding.
• I am 18 years or older.
• I have no known allergy to Ivermectin.
• I do not have severe asthma or severe liver disease.
• I do not have hyperactive onchodermatitis, concurrent loiasis, or onchocerciasis; and I understand Ivermectin can worsen bronchial asthma.

2. Treatment Purpose & Off-Label Use

• I am requesting Ivermectin as a supportive/adjunctive therapy, not as a standalone or primary treatment for cancer.
• I acknowledge that Ivermectin is not FDA-approved for the treatment or prevention of cancer and that this use is off-label and may lack large-scale clinical trial evidence.

3. Coordination With My Oncology Team

• I will inform my oncologist or cancer care provider about my use of Ivermectin and ensure they are monitoring for any adverse effects.

4. Drug Interactions

• I will accurately disclose all medications and supplements I take, including cancer therapies and blood thinners.
• I understand Ivermectin may interact with: Warfarin (Coumadin/Jantoven), Sirolimus (Rapamune), Tacrolimus (Advagraf XL/Envarsus XR), Erdafitinib (Balversa), Lasmiditan (Reyvow), Tepotinib (Tepmetko), Erythromycin (all forms), Itraconazole, Ketoconazole, Rifampin (Rifadin), and Verapamil.
• If taking Warfarin or other anticoagulants: I understand INR may increase and bleeding risk may rise; I agree to monitor INR and consult my provider as needed.

5. Monitoring & Side Effects

• I agree to contact my primary care provider or seek emergency help if I experience severe symptoms while taking Ivermectin.
• I have reviewed the medication guide: medlineplus.gov/druginfo/meds/a607069.html.
• Potential side effects include nausea, dizziness, itching, diarrhea, muscle pain, or low blood pressure.

6. How the Medication is Provided

• I understand that Ivermectin may be custom-compounded using USP-grade active ingredients by a licensed pharmacy.
• Dosing may be based on weight and my clinical profile at the provider’s discretion.

7. 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 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 or State ID or Passport (or photo of any government-issued ID) ready on this device to upload.

8. Consent, Risks & Liability

• I give consent to RightMD Inc. and its affiliated medical and pharmacy teams to evaluate me and, if appropriate, provide Ivermectin for supportive cancer care.
• I accept the risks of off-label use and understand outcomes are not guaranteed. To the extent permitted by law, RightMD Inc., its providers, pharmacies, and staff are not liable for adverse outcomes arising from my failure to disclose information, non-adherence, or misuse of the medication.

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.