COVID 19 Form

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Monoclonal Antibody for COVID-19 Infection
Outpatient Infusion Referral Form

Patient First Name:*

Patient Last Name:*

Patient DOB:*

Patient’s phone number:*

Date of positive COVID-19 test:*

N/A

Testing Clinic Name and City/State:*

Date of onset of symptoms:*

N/A

Weight (lbs):*

Patient must be 12 years of age or older, weigh at least 40 kg / 88.1849 lbs, and meet appropriate criteria.
Please select one:

For the treatment of mild to moderate COVID-19 (must meet at least one high-risk qualification below)

In adults and pediatric patients with POSITIVE results of direct SARS-CoV-2 viral testing who are 12 years of age and older weighing at least 40 kg, and who are at high risk for progressing to severe COVID-19 and/or hospitalization.

For post-exposure prophylaxis for individuals who are: (must still meet high-risk qualification below)

Not fully vaccinated or who are not expected to mount an adequate immune response to complete SARSCoV-2 vaccination (for example, people with immunocompromising conditions, including those taking immunosuppressivemedications) AND

who meet close contact criteria per Centers for Disease Control and Prevention meaning they have been exposed to an individual infected with SARS-CoV-2 (laboratory-confirmed or a clinically compatible illness) for a cumulative total of 15 minutes or more over a 24-hour period.
OR
who are at high risk of exposure to an individual infected with SARS-CoV-2 because of occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting (for example, nursing homes or prisons)

High-risk qualifications (minimum of 1 required, check all that apply):*

Age ≥ 65 years old

Obesity or being overweight (for example, adults with BMI >25 kg/m2, or if age 12-17, have BMI ≥85th percentile for their age and gender based on CDC growth charts)

Pregnancy

Chronic kidney disease

Diabetes

Immunosuppressive disease or immunosuppressive treatment

Cardiovascular disease or hypertension

Chronic lung diseases

Sickle cell disease

Neurodevelopmental disorders (for example, cerebral palsy) or other conditions that confer medical complexity (for example, genetic or metabolic syndromes and severe congenital anomalies)

Having a medical-related technological dependence (for example, tracheostomy, gastrostomy, or positive pressure ventilation (not related to COVID-19))

Medical condition or factor that places patient at high risk for progression to severe COVID-19 as directed by CDC

As the referring provider, I attest that this patient does NOT require oxygen due to COVID-19 OR does NOT require an increase in baseline oxygen flow rate due to COVID-19 in those on chronic oxygen therapy due to underlying non-COVID-19 related comorbidity.

Baseline oxygen requirement if using for non-COVID-19 comorbidities such as COPD is

As the referring provider, I have reviewed the benefits and risks of the monoclonal antibody infusion with the patient and provided the EUA fact sheet for patients/caregivers. I also confirm that I have reviewed the lab results.

Referring Provider:*

Date/Time:*

Diagnosis:

Patient’s Social Security Number:*

Facility will call patient to schedule infusion

WRMC Covid Infusion Center 870-613-0491

COVID 19 Form

Monoclonal Antibody for COVID-19 InfectionOutpatient Infusion Referral Form

Monoclonal Antibody for COVID-19 Infection
Outpatient Infusion Referral Form