COVID Treatment Request Form
Paxlovid and other oral medications may reduce the severity of COVID-19 for some patients. Please complete this screening questionnaire to see if you may be eligible for free treament. It is fine to fill this form out for someone else who asks you for help filling it out. Priority is given based on risk and supply.
Patient Information
Today's Date
I am filling this out for
*
Myself
Someone Else
Have you tested Positive for COVID-19?
*
Yes
No
Date of Positive COVID test
*
Do you have symptoms of Covid-19?
*
None, I had a positive test only
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
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Conditions which increase risk of complications from COVID-19
*
Older age (Ex: age ≥65 years of age)
Obesity or being overweight
Pregnancy
Chronic kidney disease
Diabetes
Immunosuppressive disease or immunosuppressive treatment (like daily prednisone)
Heart disease (including congenital heart disease)
Hypertension
Lung diseases (Ex: chronic obstructive pulmonary disease, asthma [moderate-to-severe], interstitial lung disease, cystic fibrosis, or pulmonary hypertension)
Sickle cell disease
Neurodevelopmental problems (Ex: cerebral palsy) or other conditions that confer medical complexity (Ex: genetic or metabolic syndromes, or severe congenital anomalies)
Having a medical-related technological dependence (Ex: tracheostomy, gastrostomy, or positive pressure ventilation not related to COVID-19)
Other
Weight in pounds
*
Height in inches
Have you been vaccinated against COVID-19?
*
Yes
No
Partially
Is there anything else you feel we should know?
Submit
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