Monoclonal Antibody Form

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Monoclonal Antibody Form

Patient Demographics
Section A: EUA Mandatory Provider Requirements
Section B: Patient Qualifiers

Patient must meet one of the following criteria (mark all that apply):

If vaccinated, has patient received a booster?*

By signing below, I attest that the patient meets the FDA emergency use authorization (EUA) for monoclonal antibodies and the information on this form is accurate to the best of my knowledge.