1. Eligibility & Safety

• I am not allergic to Ivermectin.
• I am not pregnant or breastfeeding at this time.

2. Condition & Diagnosis

• I will state the primary reason for requesting Ivermectin 1.1% cream (e.g., rosacea, head lice, scabies, acne/pimple bumps, skin cancer, eczema, psoriasis, or other inflammatory skin conditions).
• I will indicate if a clinician has diagnosed this condition and, if yes, who and when.
• I will specify the areas I plan to treat (e.g., face—cheeks/nose/chin, scalp, body areas).

3. Current Treatments & Medications

• I will disclose any known drug or topical product allergies (e.g., preservatives, fragrance, lanolin) and list them if present.
• I will disclose any prior topical Ivermectin use (strength, duration, and reason).
• I will indicate if I am using other topical products on the same areas (e.g., retinoids, benzoyl peroxide, antibiotics/steroids, azelaic acid, permethrin/spinosad) and list them if applicable.
• I will list all current medications or supplements (include dose if known).

4. Application & Use

• I confirm the areas I plan to treat do not have open wounds, ulcers, active infection, or severe irritation, and I will not apply the cream to such areas.
• I will apply a thin layer as directed, avoid eyes/lips/mucosa, wash hands after application, and stop and contact the provider if severe irritation, swelling, or rash occurs.

5. Off-Label Use (Cancer)

• I understand any cancer-related use of Ivermectin 1.1% topical cream is off-label; it is not FDA-approved for skin cancer, and I will consult a dermatologist before any such use.

6. 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), Oral Itraconazole, Oral Ketoconazole, Rifampin (Rifadin). 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.

7. How the Medication is Provided

• I understand the cream may be custom-compounded using USP-grade ingredients by a licensed pharmacy, with instructions (amount, frequency, duration) based on my condition.

8. Side Effects & When to Stop

• I have reviewed medication information and understand potential side effects may include local irritation, burning/stinging, itching, dry skin, and (rarely) hypersensitivity. I will stop use and seek care if severe reactions occur.

9. 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.

10. Consent

• I give my full consent for RightMD Inc. and its affiliated medical/pharmacy teams to prescribe and dispense Ivermectin 1.1% topical cream based on the information I have provided. I accept all risks and release RightMD Inc., its medical, pharmacy, administrative, and other affiliated teams from liability related to this treatment.

11. Payments & Refund Policy

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

12. Policies

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