1. Eligibility & Screening

• I confirm that I have no allergy to Methylene Blue.
• I will specify at least one reason for requesting Methylene Blue (Cancer-related support, Depression, Chronic Fatigue Syndrome, Long COVID, Low Energy, Brain Fog) and describe my symptoms and duration.
• I will list all current medicines and supplements (include dose if known).

2. Medication Exclusions

• I confirm I am not taking any of the following:
  • SSRI antidepressants (e.g., Zoloft, Lexapro, Prozac, Paxil, Celexa, Luvox)
  • SNRI antidepressants (Effexor, Pristiq, Cymbalta, Fetzima)
  • Other antidepressants (mirtazapine, trazodone, vortioxetine, vilazodone, nefazodone, amitriptyline, clomipramine, imipramine) or anxiety meds such as buspirone
  • MAO-inhibitors (Nardil, Parnate, Marplan, Emsam, Azilect, Xadago) in the past 14 days
  • Linezolid (Zyvox) or Methylene Blue injections within the past 14 days
  • Cough/cold meds with dextromethorphan (DM)
  • Migraine meds (sumatriptan, rizatriptan, zolmitriptan, eletriptan, almotriptan, frovatriptan, naratriptan)
  • Pain meds (tramadol, meperidine, methadone, fentanyl)
  • Herbal/serotonergic products (St. John’s wort, 5-HTP, L-tryptophan, SAMe)
  • Mood stabilizers or stimulants such as lithium, Adderall, Vyvanse, Ritalin, pseudoephedrine, or ephedrine

3. Medical Conditions

• I confirm I do not have a history of G6PD deficiency, hemolytic anemia, or have been told I might be G6PD-deficient.
• I confirm I do not have kidney disease or severe liver disease.
• I confirm I do not have a history of serotonin syndrome, bipolar disorder, mania, psychosis, or uncontrolled anxiety.
• I confirm I have not received IV Methylene Blue or linezolid within the past 2 weeks.
• I will provide my weight (lbs) for dosing.
• I confirm I am not pregnant or breastfeeding and will inform my provider if this changes.

4. Precautions & Interactions

• I understand Methylene Blue acts as an MAO-A inhibitor; I will avoid serotonergic or contraindicated drugs, follow washout periods, and not add new meds without approval.
• I understand all listed uses are off-label; results may vary, and dosing will be individualized.
• I understand potential side effects:
  • Blue-green discoloration of urine/stool/saliva
  • Nausea, abdominal discomfort, diarrhea, headache, dizziness, anxiety, or insomnia
  • Elevated blood pressure or heart rate
  • Skin or mucosal discoloration
  • Rarely: hemolysis in G6PD deficiency
• I will seek urgent care if I develop symptoms of serotonin syndrome (agitation, tremor, fever, shivering, diarrhea) or hemolysis (dark urine, jaundice, unusual fatigue).
• I understand Methylene Blue may interfere with pulse oximeters and will inform healthcare providers if I am taking it.

5. Medication Information

• This medicine may be compounded with USP-grade ingredients by a licensed pharmacy.
• I will follow my prescribed dose, timing, and duration and report any new medications or procedures.

6. Identification & Confidentiality

• Uploading a valid government-issued photo ID is a legal requirement before consultation completion.
• My personal data and ID will be securely handled and confidential, shared only as required by law or for medical care.

IMPORTANT: Please keep a clear image of your Driver’s License / State ID / Passport ready to upload.

7. Consent

• I give my full consent for RightMD INC and its affiliated medical/pharmacy teams to prescribe and dispense Methylene Blue capsules based on the information I provide.
• I accept all risks and release RightMD INC, its medical, pharmacy, administrative, and other affiliated teams from liability related to this treatment.

8. Policies

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