Patient Prescreen Form

Paxlovid Patient Information Form

Please complete this form to see if you are eligible for a Paxlovid prescription.
Name*

First NameLast Name
Email*
Phone Number*
Date of Birth*

MonthDayYear
Please list any allergies (if none, please write "none"):*
Please list all medications you are currently taking, including any over-the-counter medications, vitamins and herbal supplements (if none, please write "none"):*
Do you have any of the following medical conditions? (check all that apply; if none, please click "none of the above")*

Liver DiseaseKidney DiseaseImmunosuppressive disease (or undergoing immunosuppressive therapy)DiabetesObesity (BMI > 25 in adults)Neurologic disease (cerebrovascular diseases, Down Syndrome or other neurodevelopmental disorders, or dementia)Hemoglobin disorder (sickle cell, thalassemia)Cardiovascular disease (congenital heart disease, heart failure, CAD, Cardiomyopathy, or pulmonary HTN or Hypertension)Chronic lung disease (COPD/emphysema, moderate-severe asthma, CF, pulmonary fibrosis)Medical-related technological dependence (tracheostomy, gastrostomy, or positive pressure ventilation not related to COVID-19)Pregnant or planning to become pregnantBreastfeeding a childNone of the above
If you have any serious medical conditions not listed above, please list them here:
When did you first start experiencing COVID-19 symptoms?*

MonthDayYear
Which symptoms are you experiencing? (check all that apply)*

CoughFever or chillsShortness of breath or difficulty breathingFatigueMuscle or body achesHeadacheNew loss of taste or smellSore throatCongestion or runny noseNausea or vomitingDiarrheaNo symptoms
Have you taken a COVID-19 test?*

Yes, and my result was positiveYes, and my result was negativeYes, and my result was inconclusive or invalidYes, and I am waiting to receive my resultNo, I have not taken a test
What type of COVID-19 test did you take?*

At-home Antigen test (such as BinaxNow, Flowflex, QuickVue or iHealth)At-home Molecular test (such as Cue, Detect or Lucira)Antigen test administered by a healthcare professionalRapid Molecular test administered by a healthcare professionalLab PCR test administered by a healthcare professional
If you tested outside of modMD, please upload your COVID-19 test result here. If you tested with modMD, you do not need to upload your result.

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Paxlovid Patient Information Form