H&P Certification — Tirzepatide (Tirz)

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

By completing my purchase of Tirzepatide (Tirz) 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 Tirzepatide (Tirz)

I confirm that I:

• am using or requesting this medication as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management or other clinically appropriate purposes.

• do not have a personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2).

• have not experienced hypersensitivity reactions to tirzepatide or its components.

• understand that tirzepatide is not indicated for type 1 diabetes or diabetic ketoacidosis.

• understand and accept potential risks, including:

  • Pancreatitis (sudden, severe abdominal pain possibly radiating to the back)

  • Gallbladder disease (pain in the upper right abdomen, shoulder pain, pale stools, dark urine, yellowing of skin or eyes)

  • Kidney injury, particularly when dehydrated or vomiting

  • Delayed gastric emptying, which can affect absorption of other medications

  • Diabetic retinopathy, with possible vision changes in diabetic patients

  • Hypoglycemia, especially when used with insulin or insulin secretagogues

  • Serious allergic reactions, including anaphylaxis and angioedema

• will not use tirzepatide concurrently with other GLP-1 receptor agonists.

• understand that tirzepatide may reduce the effectiveness of oral contraceptives; I will use a non-oral or barrier method for at least 4 weeks after starting or increasing the dose.

• will monitor for mood changes, depression, or suicidal thoughts, and report them promptly.

• understand that this medication is not to be used while pregnant or breastfeeding, and I will discontinue treatment and inform a provider if pregnancy occurs.

• will maintain adequate hydration and have my body weight monitored regularly.

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 tirzepatide.

• I can find more detailed information at:

  • www.fda.gov

  • www.drugs.com/drug_interactions.html

• 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.

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