Monoclonal Antibody Form

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Monoclonal Antibody Form

Patient Demographics

First Name:*

Last Name:*

Date of Birth:*

Social Security Number (last 4 digits):*

Patient Daytime Phone Number:*

Section A: EUA Mandatory Provider Requirements

Patient is SARS-CoV-2 positive: Treatment must be administered within seven (7) days of symptom onset.

Date of Positive Test:*

Location of Positive Test:*

Date of onset of symptoms:*

As the referring provider, I have reviewed the information contained within the Fact Sheet for Patients and Caregivers with the patient/caregiver prior to the patient receiving monoclonal antibodies. The patient received an electronic and/or hard copy of the Fact Sheet for Patients and Caregivers.*

As the referring provider, I attest that the patient does not require oxygen therapy due to COVID-19, or does not require an increase in baseline oxygen flow rate due to COVID-19.*

Section B: Patient Qualifiers

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

If vaccinated, has patient received a booster?*

Yes

Contraindications for Paxlovid*

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.

Date:*

Signature:*