*Evusheld* COVID-19 mAb Registration Form

*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
Last Name*
First name*
Date of Birth*

MonthDay Year
Date
Gender*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Race*
Ethnicity*
Emergency Contact Name Please enter name*
Relationship Please enter relationship*
Phone number Enter Phone number*

Screening Questions
1. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressant drugs or therapies? *
2. Are you feeling sick today?*
3. In the last week, have you had symptoms of COVID-19? (ex. fever, cough, SOB, congestion, upset stomach, etc) *
4. In the last week, have you had a known exposure to COVID-19? *
5. Have you ever received a dose of a COVID-19 vaccine?*
If you answer Yes for question 5, Please specify
Date of last dose
6. Have you received any vaccines in the last 14days?*
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19? *
8. Do you have a bleeding disorder or are you taking blood thinner? *
9. Have you ever had a heart attack, blood clot, or stroke?*
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)   *
11. Are you pregnant or breastfeeding?*

Insurance and Payment Information
Please upload a copy of your Insurance Card(s)*

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Cancelof
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)
Medicare part B ID number*
Medicaid
Medicaid ID number*
Other Medical Insurance
ID number*
Medical Group number*
Relation code*
Uninsured (HRSA)
SSN*
ID/Driver License Number*
State of Issuance *

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.
Patient Consent/Signature (or parent/guardian if patient is age 18 or under)

Clear
Date

MonthDay Year
Date
Should be Empty:

*Evusheld* COVID-19 mAb Registration Form

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

Medicaid

Other Medical Insurance

Uninsured (HRSA)

Evusheld COVID-19 mAb Registration Form