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 for supportive use related to COVID-19, including early outpatient treatment or symptom management.
• I acknowledge that Ivermectin is not FDA-approved for the treatment or prevention of COVID-19. Its use here is off-label and considered experimental.
• I understand that FDA-approved alternatives (e.g., Paxlovid) are available through consultation with a primary care provider. I choose to proceed with Ivermectin after consulting a licensed provider and accept all associated risks.

3. Drug Interactions

• I will accurately disclose all medications and supplements I take.
• 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.

4. Medical History & Screening

• I will disclose any prior COVID-19 diagnosis and relevant details.
• I will disclose all current/past medical conditions, allergies, and prior Ivermectin use (dose and duration).
• I will disclose if I am currently taking Ivermectin from another source.
• I will list all current medications and supplements.

5. Monitoring & Side Effects

• I agree to seek immediate medical attention if my condition worsens or I experience severe reactions 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 the Ivermectin provided may be custom-compounded using USP-grade active ingredients by a licensed pharmacy.
• Dosing may be based on my weight and 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 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 or State ID or Passport (or photo of any government-issued ID) ready on this device to upload.

8. Consent, Risks & Liability

• I give my full consent for RightMD Inc. and its affiliated medical/pharmacy teams to prescribe and dispense Ivermectin for COVID-19-related care based on the information I provide.
• 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.