Diclegis (Doxylamine / Pyridoxine)
H&P Certification — Diclegis (Doxylamine / Pyridoxine)
KosherMedications.com
Health & Physical (H&P) Self-Assessment Declaration
By completing my purchase of Diclegis (Doxylamine / Pyridoxine) 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 assessment 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 medications are dispensed only if medically appropriate, based on my self-assessment and provider review.
acknowledge that a licensed healthcare provider may contact me for clarification or additional information before approval.
have reviewed and accepted KosherMedications.com’s Terms of Service and Consent to Telehealth, which govern my use of this platform and related 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 follow-up with my primary provider.
Because of the nature of telemedicine, the reviewing provider cannot continuously monitor my condition, lab values, 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 Diclegis (Doxylamine / Pyridoxine)
I confirm that I:
am using or requesting this medication for the treatment of nausea and vomiting of pregnancy (NVP), as determined appropriate by a licensed provider.
understand that Diclegis is a combination of an antihistamine (doxylamine) and vitamin B6 (pyridoxine), intended for use during pregnancy when lifestyle and dietary measures alone are insufficient.
have not experienced hypersensitivity or allergic reactions to doxylamine, pyridoxine, or any other ingredients in the formulation.
do not have conditions or medical history that would make this medication inappropriate, including:
asthma or other lower respiratory disorders aggravated by antihistamines
glaucoma or urinary retention (including bladder neck obstruction)
peptic ulcer disease, intestinal obstruction, or pyloroduodenal obstruction
hepatic impairment or severe liver disease
am not currently taking other central nervous system depressants, including opioids, sleep aids, tranquilizers, or alcohol, as these may increase drowsiness or respiratory depression.
am not currently taking monoamine oxidase inhibitors (MAOIs) or have not used them within the past 14 days, as combining them with antihistamines may cause severe reactions, including hypotension and CNS depression.
understand that Diclegis can cause drowsiness, dizziness, and impaired coordination, and I will avoid driving or operating machinery until I know how the medication affects me.
understand that Diclegis should be taken at bedtime on an empty stomach, as directed, and that dose adjustments should only be made under medical supervision.
understand that taking more than the recommended dose may result in serious side effects such as excessive sedation, confusion, or cardiac rhythm abnormalities.
will contact my healthcare provider immediately if I experience shortness of breath, heart palpitations, persistent vomiting, severe dizziness, or signs of allergic reaction such as rash, swelling, or difficulty breathing.
understand that Diclegis is intended for use during pregnancy, and I will discontinue use once symptoms resolve or as directed by my healthcare provider.
am aware that Diclegis is not indicated for hyperemesis gravidarum requiring hospitalization or for non-pregnancy-related nausea.
Health Status & Representations
I attest that I:
am in generally good health, apart from the condition for which I am seeking care.
have truthfully disclosed all relevant medical history, medications, and allergies.
understand that my submission may be reviewed by a licensed provider, who may reach out for clarification before issuing a prescription.
confirm that this certification represents all relevant information I would disclose during an in-person medical visit.
General Information About Prescription Medications
I understand that:
This certification does not list every possible precaution, risk, or side effect related to Diclegis.
I can find more detailed information at:
I will review the Medication Guide included with my prescription and consult my healthcare provider if I have further questions.
Pharmacy & Fulfillment Information
I acknowledge that:
KosherMedications.com partners with licensed pharmacies to dispense medications in accordance with state and federal law.
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 prior to taking my 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.