COVID-19 Infusion Treatment for Symptomatic Patients

COVID-19 Infusion Treatment for Symptomatic Patients Providers, please complete the following checklist to determine if your patient is eligible for a referral. All fields marked with an * are required. You must have JavaScript enabled to use this form. NOTICE: Treatment Criteria and Availability Treatment is only available to Virginia residents at this time. Please complete the form below to refer a symptomatic patient for treatment. Note that you (or your patient) 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 patience. If the patient is experiencing significant symptoms, please have them contact their primary care physician or seek urgent care. 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 indicate which infusion you are referring a patient for: Remdesivir Infusion Monoclonal Antibody Infusion Enter patient's height and weight BMI > or = 30 (or > 85th percentile if < 18 years old) Yes No Don't know Comments Illness onset within past 7 days? Yes No Date of Onset of COVID-19 Symptoms Date of Positive COVID-19 Test Comments Age 65 or older? Yes No Risk Factors: CHECK ALL THAT APPLY Please mark all the risk factors that currently apply to the patient you are referring. 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 Pregnancy Chronic kidney disease Diabetes Cardiovascular disease (including hypertension, atrial fibrillation, heart failure, valvular heart disease, pulmonary hypertension, or history of stroke) Chronic lung diseases (for example, chronic obstructive pulmonary disease, asthma, interstitial lung disease, cystic fibrosis and pulmonary hypertension) 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, e.g. tracheostomy, gastrostomy, or positive pressure ventilation (not related to COVID-19) None of these apply Please specify the immunosuppressive disease, treatment or medication that the patient is currently taking. Please specify the specific cardiovascular disease and which medication that the patient is currently taking. Comments Does your patient qualify for Paxlovid? Yes (If yes, consider prescribing Paxlovid instead) No Not Sure 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.