1. Eligibility & Safety

• I am not allergic to Ivermectin.
• I am 18 years or older and not pregnant or breastfeeding.
• 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 Long COVID, including symptom management.
• I acknowledge that Ivermectin is not FDA-approved for the treatment of Long COVID; this use is off-label and investigational.
• I understand there are currently no FDA-approved medications specifically for Long COVID. I choose to proceed with Ivermectin after consultation with a licensed provider and accept all associated risks.

3. Medical History & Screening (What I Will Disclose)

• My last COVID-19 diagnosis date (month and year).
• My current Long COVID symptoms (e.g., fatigue, brain fog, shortness of breath, chest pain, joint/muscle aches, palpitations, insomnia, anxiety, depression, persistent cough).
• Any current/past medical conditions and known drug allergies.
• Whether I have taken Ivermectin before (with dose and duration) and whether I am currently taking Ivermectin from another source.
• All current medications and supplements.
• My weight in pounds (for weight-based dosing if appropriate).

4. 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.

5. Monitoring & Side Effects

• I agree to contact my primary care provider or seek emergency help if I experience severe side effects or worsening 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 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 consent for RightMD Inc. and its affiliated medical and pharmacy teams to provide Ivermectin for supportive use in Long COVID 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 .