Nitrofurantoin
H&P Certification — Nitrofurantoin (UTI Relief)
KosherMedications.com
Health & Physical (H&P) Self-Assessment Declaration
By completing my purchase of Nitrofurantoin (UTI Relief) 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 Nitrofurantoin (UTI Relief)
I confirm that I:
am using or requesting this medication for the treatment of acute, uncomplicated urinary tract infections (UTIs) caused by susceptible strains of Escherichia coli or Staphylococcus saprophyticus.
understand that Nitrofurantoin is not indicated for kidney infections (pyelonephritis) or perinephric abscesses.
have not experienced allergic or hypersensitivity reactions to nitrofurantoin or any of its components.
do not have a history of renal impairment (creatinine clearance below 60 mL/min), anuria, or oliguria.
do not have a history of cholestatic jaundice or liver dysfunction associated with prior nitrofurantoin use.
do not have a diagnosis of G6PD deficiency, which may increase risk of anemia.
understand that Nitrofurantoin should be taken with meals to improve absorption and reduce gastrointestinal side effects.
am aware that long-term or inappropriate use can cause pulmonary toxicity, hepatotoxicity, or peripheral neuropathy, particularly in older adults.
understand that Nitrofurantoin may, in rare cases, cause Clostridioides difficile infection or secondary fungal overgrowth after prolonged use.
am not currently taking medications known to interfere with Nitrofurantoin’s effectiveness or excretion, including magnesium trisilicate, probenecid, or norfloxacin.
will monitor for symptoms such as shortness of breath, cough, jaundice, tingling sensations, or persistent diarrhea, and seek prompt medical attention if these occur.
am not pregnant or breastfeeding, and will notify a provider if that changes before starting or continuing treatment.
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 Nitrofurantoin.
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.