COVID-19 Infusion Treatment for Symptomatic Patients

COVID-19 Infusion Treatment for Symptomatic Patients Patients, please complete the following form to submit a request for treatment referral. All fields marked with an * are required. Note: If you are a provider and want to submit a referral for a patient, use this form.  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 submit the form below if you are symptomatic 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 patience. If you are experiencing significant symptoms, please contact your primary care physician or seek urgent care. If you are scheduled for treatment, please bring a copy of your COVID-19 test results if your test was done outside of Inova. 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 Patient's height and weight BMI >= 25 (or >= 85th percentile if 18 years old or younger) Yes No Don't know Comments Illness onset within the past 7 days? Yes No What date did you first start to experience COVID-19 symptoms? (Including fever, cough, body aches) Date of Positive COVID-19 Test Location of 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 you. In order to treat every patient appropriately, it is important that you indicate all of your risk factors. 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 your immunosuppressive disease, treatment or medication that you are currently taking. Please specify your specific cardiovascular disease and which medication that you are currently taking. Comments Has your healthcare provider prescribed you a medication called Paxlovid? Yes No Not Sure Patient Information (Parents, if you are referring a child please enter your contact information in the first section) Patient First Name Patient Last Name Patient Phone Patient Age Patient Email Name of Primary Care Provider (if applicable) 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.