1. Eligibility & Safety

• I am not allergic to Ivermectin.
• I am not pregnant or breastfeeding at this time.
• I do not have Severe Asthma or Severe Liver Disease.
• I do not have hyperactive Onchodermatitis, Concurrent Loiasis, or Onchocerciasis (I understand Ivermectin may worsen bronchial asthma).

2. Medical History & Screening

• I will disclose any known drug allergies and list them if present.
• I will disclose any prior Ivermectin use and provide the dose, duration, and reason if applicable.
• I will report whether I am currently experiencing symptoms suggestive of COVID-19 active infection (e.g., fever, cough, sore throat, shortness of breath, loss of taste/smell) and list them if present.
• I will list all current medications and supplements (include doses if known).
• I will disclose any current or past medical conditions.
• I will provide my weight (lbs).

3. Drug Interactions

• I understand Ivermectin may interact with: Warfarin (Coumadin/Jantoven), Sirolimus (Rapamune), Tacrolimus (Advagraf XL, Envarsus XR), Erdafitinib (Balversa), Lasmiditan (Reyvow), Tepotinib (Tepmetko), Erythromycin (ethylsuccinate, lactobionate, stearate), Itraconazole, Ketoconazole, Rifampin (Rifadin), and Verapamil. I agree to accurately disclose my medications and follow medical guidance.
• If taking Warfarin or other anticoagulants: I understand Ivermectin may increase INR and bleeding risk; I agree to monitor INR and consult my provider if needed.

4. Purpose & Regulatory Status

• I am requesting Ivermectin for supportive use in COVID-19 prevention (prophylaxis) as determined appropriate by a licensed provider.
• I understand Ivermectin is not FDA-approved for the prevention of COVID-19; its use for prophylaxis is off-label and investigational. I am choosing to proceed after consultation and accept all associated risks.

5. How the Medication is Provided

• The Ivermectin provided may be custom-compounded using USP-grade active ingredients by a licensed pharmacy and will be dosed based on my weight and clinical profile.

6. Monitoring & Side Effects

• I agree to seek immediate medical attention and notify the provider if I develop COVID-19 symptoms, test positive, or experience any severe side effects while taking Ivermectin.
• I have reviewed the medication guide: medlineplus.gov/druginfo/meds/a607069.html, and understand potential side effects may include dizziness, skin itching, nausea, diarrhea, joint or muscle pain, or low blood pressure.

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 / State ID / 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 prevention based on the information I have provided. I accept all risks and release RightMD Inc., its medical, pharmacy, administrative, and all other affiliated teams from any liability related to this treatment.

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.