H&P Certification — Custom Medication Request

KosherMedications.com
Health & Physical (H&P) Self-Assessment Declaration

By completing my purchase or submitting a custom medication request through KosherMedications.com, I certify under penalty of perjury that the following statements are true and correct to the best of my knowledge and belief. I understand that a licensed healthcare provider will rely upon this information when determining whether a prescription is clinically appropriate.

General Information

I affirm that I:

• am 18 years or older, completing this request for myself, voluntarily, and providing accurate identifying information including my full name, address, and contact details.

• will use this service and any prescribed medication solely for myself and will not share or distribute it to others.

• understand that prescriptions are issued only if medically appropriate, based on my self-reported information and provider review.

• acknowledge that a licensed healthcare provider may contact me for additional details, clarification, or documentation before approval.

• have reviewed and accepted KosherMedications.com’s Terms of Service and Consent to Telehealth, which govern this interaction and any resulting care.

Consent to Telehealth

I understand and acknowledge that:

• This service uses an asynchronous telehealth model, allowing me to provide health information online for review by a licensed provider.

• A valid provider-patient relationship is created for this encounter and may include follow-up communication if needed.

• Telehealth is a supplemental mode of care and does not replace in-person evaluation or ongoing monitoring by my primary provider.

• Because of the nature of telemedicine, the reviewing provider cannot continuously monitor my condition, lab results, or side effects. I accept these limitations and associated risks.

• All personal and medical information will be transmitted and stored securely, in compliance with HIPAA and applicable privacy laws.

• In the event of a medical emergency, I will call 911 or seek immediate in-person emergency care and will not rely on telehealth communication for urgent or life-threatening issues.

Clinical Information Related to My Custom Medication Request

I confirm that I:

• am requesting a specific medication or compound not listed among standard offerings on KosherMedications.com and understand that my request will be reviewed for clinical appropriateness, legality, and safety.

• have provided all relevant details about the name, strength, dosage form, and intended purpose of the medication I am requesting.

• understand that a licensed provider will review my health profile, current medications, and medical history to determine whether the requested product is safe and medically justified.

• understand that my provider may recommend an alternative medication or formulation if the one requested is not appropriate, unavailable, or non-compliant with state or federal law.

• have not experienced allergies or hypersensitivity to any ingredients likely to be present in the requested medication, or I have disclosed such reactions in my health information.

• understand that any compounded or customized medication may differ from commercially available products in formulation, concentration, or route of administration, and I will follow all instructions provided.

• understand that the safety and efficacy of custom compounds may not have been evaluated by the FDA and that use is based on individualized provider judgment and current standards of care.

• am aware that improper or unsupervised use of medications may cause side effects or adverse outcomes, and I will seek immediate medical attention if I experience concerning symptoms.

• understand that completing this request does not guarantee approval or prescription issuance, and that all decisions are made at the discretion of the licensed provider.

Health Status & Representations

I attest that I:

• am in generally good health, apart from the condition for which I am seeking treatment.

• have truthfully disclosed all relevant medical history, current medications, supplements, and allergies.

• understand that my information may be reviewed by a licensed provider, who may reach out for clarification before issuing a prescription.

• confirm that this attestation includes all relevant medical details I would provide during an in-person visit.

General Information About Prescription Medications

I understand that:

• This certification does not list every possible precaution, risk, or side effect related to the medication I am requesting.

• I can find additional information about approved drugs at:

  • www.fda.gov

  • www.drugs.com/drug_interactions.html

• I will review the Medication Guide or compounding information provided with any prescription and consult my healthcare provider if I have additional questions.

Pharmacy & Fulfillment Information

I acknowledge that:

• KosherMedications.com partners with licensed pharmacies and compounding facilities to dispense medications in accordance with applicable laws.

• Reviewing providers act independently and are not employees of the pharmacy.

• I consent to receive education materials, refill notifications, and updates electronically.

• I am responsible for reviewing this certification and contacting support@koshermedications.com with any concerns before starting any prescribed medication.

Emergency Disclaimer

I understand that KosherMedications.com and its affiliated providers do not provide emergency medical services.
In the event of an emergency or severe reaction, I will call 911 or seek immediate in-person care at the nearest emergency department.

By completing my request or purchase, I affirm that all statements above are true, accurate, and complete to the best of my knowledge.