Monoclonal Antibody Treatment for Covid-19 Interest Form
Instructions: Complete this form in its entirety to the best of your knowledge. If you don’t know the answers to some of these questions, please leave it blank or write "NA"
Please complete form online along with a
copy of positive COVID-19 result AND a copy of insurance card if available.
For uninsured patients, the monoclonal antibody treatment is
FREE
and paid by the United States Health Resources & Services Administration's COVID-19 Program.
Once the completed paperwork has been received, a pharmacy representative will contact the patient to coordinate services as soon as possible.
Please note:
There is always the possibility that a patient's clinical condition may change during the time between referral and injection appointment, to the point where mAb therapy may no longer be indicated for the patient. If a patient has clinically declined by the time of scheduled appointment, we will refer them to a higher level of care, if needed, without administering mAb.
Required Documentations
Do you have Health Insurance?
*
Please Select
Yes
No
What is your insurance provider (insurance name) ?
*
If you are insured, please type "NA"
Please submit the required document here (insurance card, a copy of positive COVID 19 result)
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Doctor Information
Primary Care Provider
*
If you don't have a Primary Care Provider, write "N/A" in this field.
Organization
*
If you don't have a Primary Care Provider, write "N/A" in this field.
Phone Number
*
Please enter a valid phone number. If you don't know the phone number, type "410 000 0000"
Zip
Patient Information
Last name
*
First Name
*
Middle Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
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SSN
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Race
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What is your Preferred Language
*
Do you need or want an interpreter for us to communicate with you?
*
Address
*
Address 2
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City
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State
*
Zip
*
Home Phone
*
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Work phone
*
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Cell Phone
*
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Email
example@example.com
Weight (Please include unit)
*
Height (Please include unit)
*
BMI
*
Are you fully vaccinated?
*
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yes
No
Which COVID vaccine did you receive?
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Pfizer
Moderna
J&J
None
Date of first COVID dose
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-
Day
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Date
Date of second COVID dose
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Month
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Day
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Date
Date of third COVID dose
-
Month
-
Day
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Date
Have you received a positive Covid-19 PCR or Antigen Test in the last 48 hours?
*
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Yes
No
Date of positive test result
-
Month
-
Day
Year
Date
Have you had direct contact with an individual who is positive for Covid-19 in the past 72 hours?
*
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Yes
No
Symptoms onset date
-
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-
Day
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Date
Please check all the following symptoms that you are experiencing
*
Fever
Chills
Cough
Shortness of breath
Difficulty breathing
Fatigue
Headache
Muscle or body aches
New loss of taste or smell
Sore throat
Congestion
Runny nose
Nausea
Vomiting
Diarrhea
Initial here to indicate you understand that more information about the medication, Regeneron, please review the FDA EUA: https://www.fda.gov/media/145611/download
*
I consent to being treated with monoclonal antibodies for Covid-19 by Soleil Pharmacy. The therapy requires a series of 4 subcutaneous injections. (please initial bellow)
*
I understand that my appointment is not confirmed until I receive a call from Soleil Pharmacy. (please initial bellow)
*
Date
*
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-
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Date
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