I, ________________________________, (print name), ____/____/________, (date of birth)

acknowledge the risks of taking ivermectin off-label for COVID-19. I will call my doctor for
medical advice about side effects regarding ivermectin.

I understand that adverse effects may include:

 elevated heart rate  constipation
 peripheral/facial swelling  drowsiness
 orthostatic hypotension  dyspnea
 dizziness  fatigue
 diarrhea  headache
 nausea  vertigo
 abdominal pain  vomiting
 coma  weakness
 confusion

I have reviewed with the pharmacist the list of medications that I am taking to ensure there are
no interactions with ivermectin. I also understand that drinking alcohol while taking ivermectin
can add to the adverse effects of ivermectin.
Medication List

________________ ________________ ________________

________________ ________________ ________________
________________ ________________ ________________
________________ ________________ ________________
________________ ________________ ________________
Allergies: ________________________________________________________________
Patient weight:

_____________________________ ____________________
Signature Date
___________
Pharmacist Initial