• *Evusheld* COVID-19 mAb Registration 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.
    • 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 arrival to the infusion center, to the point where mAb therapy may no longer be indicated for the patient. If a patient has clinically declined by the time they arrive at Soleil Pharmacy, we will refer them to a higher level of care, if needed, without administering mAb.
    • Fact Sheet for Patients, Parents And Caregivers  
    • Patient Information  
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    • Emergency Contact Name *
      Relationship *
      Phone number   *   

    • Screening Questions  
    • If you answer Yes for question 5, Please specify
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    • 10. Have you ever had an allergic reaction to: (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital? It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
      A previous dose of EVUSHELD?   *
      A component of EVUSHELD, including polysorbate   *   
      Any other vaccine or injectable medication?   *   
      Something other than a component of EVUSHELD, polysorbate, or any vaccine or injectable medication? (This would include food, pet, environment, or oral medication allergies)   *      

    • Insurance and Payment Information  
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    • Please enter the information that apply to you only and enter N/A for other required fields

       

    • Medicare Part B (Red, White, and Blue card)

    • Medicaid

    • Other Medical Insurance

    • Uninsured (HRSA)

    • Consent  
      • I request the injections to be given to me or to the person named above, a minor for whom I represent, and I am authorized to sign this consent form.
      • I understand the benefits and risks of EVUSHELD as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this consent form (online or in print).
      • I have had a chance to ask questions that were answered to my satisfaction.
      • I agree to stay in the administration area for one (1) hour after receiving my injections to ensure that no immediate adverse reactions occur.
      • For Medicare/ Medicaid patients: I authorize the pharmacy to bill my insurance on my behalf for the treatment. 
      • For commercial Insurance patients: I understand that I may have to pay the administration fee upfront ($650), prior to receiving treatment if I have commercial insurance. Soleil Pharmacy will give me the reimbursement form to submit to my insurance company.
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