Monoclonal Antibody Appointment Request

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Have you received a COVID-19 test (Rapid Antigen or PCR) recently?* This field is required.
YESNO
2
If yes, please provide the date of your COVID-19 test.* This field is required.
Date
Month
Day
Year
3
Did you test positive or negative for COVID-19?* This field is required.
Positive
Negative
4
Do you have any of the following symptoms?* This field is required.
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
None of the above
5
Have you had close contact (within 6 feet for a total of 15 minutes or more over a 24-hour period) with someone with confirmed COVID-19 recently?* This field is required.
YESNO
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If yes, when did you have close contact (within 6 feet for a total of 15 minutes or more over a 24-hour period) with someone with confirmed COVID-19 .* This field is required.
Date
Month
Day
Year
7
Are you considered fully vaccinated based on CDC guidelines?* This field is required.Fully vaccinated: At least 2 weeks after the second dose of an mRNA vaccine (Pfizer or Moderna) or 2 weeks after a single dose of Johnson & Johnson COVID-19 vaccine.
YESNO
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If yes, when did you receive your last COVID-19 vaccine?* This field is required.
Date
Month
Day
Year
9
The following medical conditions or other factors may place adults and pediatric patients (age 12-17 years and weighing at least 40 kg) at higher risk for progression to severe COVID-19. Please select one or more medical condition or factors.* This field is required.Other medical conditions or factors (for example, race or ethnicity) may also place individual patients at high risk for progression to severe COVID-19 and authorization of REGEN-COV under the EUA is not limited to the medical conditions or factors listed above. For additional information on medical conditions and factors associated with increased risk for progression to severe COVID, see the CDC website: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medicalconditions.html
Older age (for example, age ≥65 years of age)
Obesity or being overweight (for example, 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 (including congenital heart disease) or hypertension
Chronic lung diseases (for example, chronic obstructive pulmonary disease, asthma [moderate-to-severe], 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 (for example, tracheostomy, gastrostomy, or positive pressure ventilation (not related to COVID 19))
None of these
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Name* This field is required.
First Name
Last Name
11
Phone Number* This field is required.
Area Code
Phone Number
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I acknowledge the information provided is accurate to the best of my knowledge.

CONSENT TO NOTIFY:

I consent that Southern Pharmacy may contact me via telephone and/or sms message using the information provided. Contact information may include REGEN-COV treatment availability, REGEN-COV treatment appointment reminders, and other healthcare information.

View the Southern Pharmacy privacy policy here.

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