Evusheld Online Self-referral Form for COVID-19 Negative Patients

You must have JavaScript enabled to use this form. Evusheld Online Self-Referral Form for COVID-19 Negative Patients NOTICE: Treatment Criteria and Availability Please submit the form below if you are COVID-19 negative and meet the criteria noted. Note that you will ONLY receive a call to schedule a treatment if: 1) patient meets the current eligibility criteria; and 2) we have supply available. Thank you for your understanding. Note: Google Chrome is recommended as the optimal browser for this form.  Patient Age and Weight 12 years and older and weight is equal to or greater than 40 kg 11 years or younger and weight is equal to or greater than than 3.5 kg but less than 40 kg Please confirm that the patient is not currently infected with SARS-CoV-2 and has not had a known recent exposure to an individual infected with SARS-CoV-2 [within past 2 weeks?] Yes No Risk Factors: CHECK ALL THAT APPLY Please mark all the risk factors that currently apply to the patient requesting referral. In order to treat every patient appropriately, it is important that all relevant risk factors are noted. Patient with one or more of the following risk factors for severe COVID-19? Moderate to severe immunocompromised due to a medical condition or receipt of immunosuppressive medications or treatments Vaccination with any available COVID-19 vaccine, according to the approved or authorized schedule, is not recommended due to a history of severe adverse reaction (e.g., severe allergic reaction) to a COVID-19 vaccine(s) and/or COVID-19 vaccine component( Patient Information Patient First Name Patient Last Name Patient Age Patient Phone Patient Email Name of Referring Provider Provider Phone Provider Email CONFIDENTIALITY NOTICE: Your answers may be sent via email over the internet and may not be secure. Although it is unlikely, there is a possibility that information you include can be intercepted and read by other parties besides the person to whom it is addressed. Once received, lnova shall take every precaution to maintain adequate physical, procedural and technical security with respect to our offices and the information storage facilities so as to prevent any loss, misuse, unauthorized access, disclosure or modification of the user's personal information under our control.