FULL H&P CERTIFICATION — MIC INJECTIONS

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

By completing my purchase of MIC Injections 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 or compounded preparation 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 MIC Injections may be dispensed only if medically appropriate, based on my self-reported information and provider review.

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

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

Consent to Telehealth

I understand and acknowledge that:

• This service uses an asynchronous telehealth model, allowing me to provide medical 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 values, or side effects. I accept these limitations and 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 MIC Injections

I confirm that I:

• understand that MIC Injections (Methionine, Inositol, and Choline) are lipotropic compounds used to support healthy liver function, fat metabolism, and overall wellness — and are not FDA-approved for weight loss or any specific medical indication.

• understand that MIC formulations may include B vitamins or other supportive nutrients depending on the compounded preparation.

• have not experienced hypersensitivity or allergic reactions to Methionine, Inositol, Choline, B vitamins, or any component of the formulation.

• do not have medical conditions that may increase risks, including:

  • severe liver disease or cirrhosis

  • significant kidney impairment

  • active infection or fever

  • untreated thyroid disorders

  • cardiovascular disease requiring intensive monitoring

• understand that MIC injections may cause side effects, including:

  • nausea or stomach upset

  • headache

  • mild diarrhea

  • dizziness

  • injection site redness or discomfort

  • rare allergic reactions

• understand that certain formulations contain sulfur-containing amino acids, and I have disclosed any history of sulfa or sulfur sensitivity.

• understand that MIC Injections should be used alongside, not instead of, evidence-based lifestyle measures such as nutrition and exercise.

• will discontinue use and seek medical attention if I experience:

  • chest pain

  • difficulty breathing

  • severe dizziness

  • widespread rash or swelling

  • signs of liver or kidney distress

• am not pregnant or breastfeeding, and will notify a provider if this changes.

• will inform my reviewing provider of all current medications, supplements, and herbal products, as some metabolic supplements may interact with liver enzyme pathways.

• understand that MIC Injections are frequently compounded, and compounded medications are not FDA-approved but are produced in licensed compounding facilities per U.S. standards.

Health Status & Representations

I attest that I:

• am in generally good health, apart from the goals for which I am seeking MIC support.

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

• understand that my submission may be reviewed by a licensed provider, who may request additional information before issuing a prescription.

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

General Information About Prescription or Compounded Medications

I understand that:

• This certification does not list all risks, interactions, or side effects associated with MIC Injections.

• MIC formulations may be compounded, and compounded medications are not reviewed or approved by the FDA.

• Additional medication interaction information is available at:

  • www.fda.gov

  • www.drugs.com/drug_interactions.html

• I will review any instructions or compounding documentation included with my prescription and consult a provider if I have further questions.

Pharmacy & Fulfillment Information

I acknowledge that:

• KosherMedications.com partners with licensed pharmacies and compounding facilities 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, updates, and refill notifications electronically.

• I am responsible for reviewing this certification and contacting support@koshermedications.com with any questions before starting treatment.

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