Informed Consent for Skin Care Treatments and Medications

PLEASE READ THIS DOCUMENT CAREFULLY.

1. Overview of Skin Care Treatment

You are being evaluated for a treatment plan designed to improve skin health and address concerns such as:

• Acne or acne scarring
• Hyperpigmentation or melasma
• Fine lines, wrinkles, or sun damage
• Rosacea or inflammation
• General texture or complexion issues

Treatment may include prescription medications, topical compounds, and customized skin formulations tailored to your skin type and clinical condition.

2. Medications That May Be Prescribed

Medications and topical agents that may be prescribed include:

• Tretinoin or retinoids (topical or compounded)
• Hydroquinone or azelaic acid
• Niacinamide, tranexamic acid, or kojic acid
• Topical antibiotics (for example, clindamycin or erythromycin)
• Oral medications for acne (for example, doxycycline or spironolactone)
• Compounded creams or serums with multi-ingredient formulations
• Hydration, exfoliation, or skin barrier support agents

These treatments may help reduce breakouts, improve tone and texture, and support skin regeneration.

3. Disclosure Regarding Compounded Medications

Some medications may be compounded, meaning they are customized by licensed U.S. pharmacies to meet your unique skin care needs.

Please note:

• Compounded skin care medications are not FDA approved, but they are prepared in compliance with federal and state laws.
• They are only dispensed with a valid prescription from a licensed provider.
• DrWell works exclusively with licensed pharmacies and is a LegitScript Enterprise Certification Partner for Healthcare, which supports lawful, transparent, and safe practices in telehealth and pharmacy operations.

4. Off-Label Use Disclosure

Certain skin care treatments may be prescribed for off-label use, which means using a medication for an indication not specifically listed in its FDA approval. This is a legal and common medical practice, particularly in dermatology.

Your provider will explain any such uses and the clinical reasoning behind them.

5. Potential Risks and Side Effects

As with all medical treatments, there are potential side effects, which may include:

• Skin irritation, redness, or dryness
• Sensitivity to sunlight (photosensitivity)
• Peeling or flaking
• Allergic reactions or rashes
• Hormonal effects, if oral medications are used
• Temporary worsening before improvement

You agree to follow all application and care instructions, including sun protection and avoidance of known irritants.

6. No Guarantees or Promises

Results from skin care treatments vary based on skin type, age, adherence, and other individual factors. While many patients benefit from these therapies, no specific outcome can be guaranteed.

Improvement may be gradual and require ongoing or maintenance treatment.

7. Telehealth Services and Consent

Your evaluation and follow-up care may occur via telehealth, including video visits or secure asynchronous communication.

You understand and agree that:

• Your provider is licensed in the state where you are located at the time of consultation.
• All records are maintained securely and in accordance with HIPAA.

California residents (Business and Professions Code section 2290.5)

• You may withdraw your consent to telehealth at any time.
• Your right to in-person care is not affected by use of telehealth services.

8. State Availability and Restrictions

While DrWell offers treatment in all 50 states, availability of certain topical or compounded skin care products may vary based on pharmacy regulations and state laws.

A complete consultation is required before medication is prescribed. Some treatments may be modified or unavailable in certain jurisdictions.

9. Patient Responsibilities

You agree to:

• Disclose your complete skin and medical history
• Follow usage directions exactly as provided
• Use sun protection when directed
• Notify your provider of any new symptoms or reactions
• Avoid applying any unapproved over-the-counter products that may interfere with treatment

Misuse of medications or failure to follow instructions may lead to adverse outcomes.

10. Additional Support and Information

For help with your prescription, side effects, or follow-up care, contact your provider directly.

More safety information is available at drwell.com/patient-resources.

Acknowledgment

By proceeding with treatment, you acknowledge that you have read and understood this Informed Consent. You accept the risks and responsibilities outlined and consent to receive skin care treatments and medications as prescribed by a licensed DrWell provider.