H&P CERTIFICATION — SCAR HERO

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

By completing my purchase of Scar Hero 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 this compounded scar formulation 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 medication prescribed solely for myself and will not share it with anyone else.

• understand that Scar Hero will 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 resulting 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 established for this encounter and may include follow-up communications when needed.

• Telehealth is a supplemental mode of care and does not replace in-person evaluation or routine dermatological follow-up.

• Because of telemedicine limitations, the reviewing provider cannot continuously monitor my skin healing or potential adverse reactions. I accept these limitations and associated risks.

• All personal and health information will be transmitted and stored securely according to HIPAA and state privacy laws.

• In the event of a medical emergency, I understand I must call 911 or seek immediate in-person medical care.

Clinical Information Related to Scar Hero

I confirm that I:

• understand that Scar Hero is a custom-compounded, prescription-only scar formulation containing a silicone-based medical-grade gel, Pentoxifylline, Aloe Vera extract, and Diphenhydramine, created to support scar softening, remodeling, hydration, and comfort.

• understand that Scar Hero is not FDA-approved but is compounded in licensed facilities according to U.S. compounding standards.

• am using or requesting this medication to support the appearance of:

  • surgical scars

  • burn scars

  • acne scars

  • stretch marks

  • hypertrophic or keloid-prone scars

  • older or newer scars that have completely healed

• understand that this formulation should not be applied to:

  • open wounds

  • unhealed incisions

  • actively infected skin

  • areas with scabs that have not naturally fallen off

• understand that scar massage should begin 1–2 weeks after suture removal or as directed by a provider, and only once the area is fully healed.

• have not experienced hypersensitivity or allergic reactions to:

  • silicone-based gels

  • Pentoxifylline

  • Aloe Vera extract

  • Diphenhydramine

  • plant-derived emollients

  • pharmaceutical gel bases

• do not have skin conditions or medical concerns that would make this therapy inappropriate, including:

  • active dermatitis or eczema on the scar

  • severe allergic contact dermatitis

  • widespread infection or cellulitis

  • poorly controlled diabetes with impaired wound healing

  • circulatory conditions affecting healing

• am aware that Scar Hero may cause side effects including:

  • mild redness or irritation

  • temporary itching

  • warmth or tingling

  • sensitivity during massage

  • rare allergic reactions

• understand that if I experience significant redness, warmth, bleeding, unusual pain, or worsening inflammation, I will discontinue use and contact a provider immediately.

• understand that Pentoxifylline increases blood flow, Aloe Vera may support collagen structure, and Diphenhydramine may relieve itch and help reduce excessive fibroblast activity in hypertrophic and keloid scars.

• will avoid sun exposure on the treated area and use SPF 35+ sunscreen daily, as UV exposure may worsen pigmentation and slow scar remodeling.

• understand that additional supportive measures, such as silicone sheets, may be used at night to enhance outcomes.

Health Status & Representations

I attest that I:

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

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

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

• confirm that this attestation includes all relevant medical information I would disclose during an in-person dermatology or primary care visit.

General Information About Prescription or Compounded Medications

I understand that:

• This certification does not list all risks, side effects, or interactions associated with compounded scar formulations.

• Compounded medications are not evaluated or approved by the FDA but are prepared under U.S. compounding regulations.

• Additional drug interaction information is available at:

  • www.fda.gov

  • www.drugs.com/drug_interactions.html

• I will review all instructions, usage guidelines, and compounding information provided with my prescription.

Pharmacy & Fulfillment Information

I acknowledge that:

• KosherMedications.com partners with licensed compounding pharmacies to dispense Scar Hero in accordance with state and federal law.

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

• I consent to receive education materials, follow-up reminders, and updates electronically.

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

Emergency Disclaimer

I understand that KosherMedications.com and its affiliated providers do not provide emergency medical services.
If I experience a severe reaction, I will call 911 or seek immediate in-person care.

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