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Please read the following statements and check the box if you have been diagnosed or experienced the following:

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• Attest that I will be using this medication as prescribed and for my own personal use
• Understand and am aware of the monitoring parameters for A1C levels and am completing the lab work as required
• Don't have a personal or family history of medullary thyroid carcinoma (MTC) or a history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
• Am aware and understand the symptoms of thyroid tumors (e.g., a mass in the neck, dysphagia, dyspnea, persistent hoarseness).
• Understand and am aware that HarmonifyRx has a boxed warning that indicates it is unknown whether semaglutide causes thyroid C-cell tumors.
• Understand and am aware this medication slows gastric emptying, which can alter the absorption of other medications
• Understand this medication has shown incidence of acute kidney injury, diabetic retinopathy, gallbladder disease, gastrointestinal side effects, and pancreatitis
• Understand psychiatric effects have occurred, such as suicidal thoughts, with other medications for weight management
• Understand and am aware that prolonged ingestion with excessive doses may result in dental fluorosis and/or osseous changes
• Understand that only major drug interactions are listed and have not been reviewed against the other medications, supplements, or herbal products I may be taking unless also filled by HarmonifyRx
• Understand that HarmonifyRx does not provide medical care and the providers who use HarmonifyRx to provide telehealth services (“Telehealth Providers”) should not replace your primary provider.
• Understand that the Telehealth Providers are not able to: (1) monitor ongoing health or lab values for side effects or efficacy, (2) observe how you (or your pet) tolerate any prescribed treatment, or (3) determine if the prescribed treatment is working as intended and assume any risks associated with this modality of care and waive any claim I may have in the future against HarmonifyRx and/or the Telehealth Providers.
• Understand that by using this site, I have created a patient-client-doctor relationship and I am being directed by the Telehealth Providers to consult my primary provider soon after beginning any treatment prescribed by the Telehealth Providers.
• Understand that this is a supplemental mode of care for your convenience and the Telehealth Providers are not to be used, or relied on, as a replacement for in-person follow-up visits or interactions with your primary provider.
• And I acknowledge that my physician visit is complete and I will follow up with my primary care provider as required.