Paxlovid Treatment Request Form

Paxlovid Treatment Request (Oral Antiviral Treatment for COVID-19)

Please read below carefully, fill out the form to the best of your knowledge.
Patient Name*

First NameLast Name
Have you tested Positive for COVID-19 within the last 5 days?*

YesNo
When did your symptoms start?

MonthDayYear
Date
Please upload an image of your Positive COVID test (if you have it)

Cancelof
What Date did you Test Positive for COVID-19?

MonthDayYear
Date
Primary Care Provider Name (if you have one)
Primary Care Provider Phone Number (if you have one)
Please enter a valid phone number.
Please upload a copy of your most recent labs, including kidney (renal) and liver (hepatic) functions. Lab results must be less than 12 months old.*

Kidney (renal function) labs: eGFR/CrCl, Liver (Hepatic) labs: AST, ALT
Cancelof
Patient Date of Birth (Must be 12 years of age and older)*

MonthDayYear
Date Of Birth
How much does the patient weigh in pounds? (Must weigh at least 88 pounds for treatment)*
Weight in pounds
What is the patient's height? (inches)
Unfortunately, you do NOT qualify for Paxlovid treatment according to the FDA/CDC guidelines.

You may now exit this form.

Patient Demographic Information
Patient Address*

AddressOne

AddressTwo

CityStateCode

ZipCountry
Patient Gender: (M: Male and F: Female and U: Other)*

MFU
Patient Cell Phone Number: (Please double check for accuracy)*
Please enter a valid phone number. Only enter the numbers no ( ) or dashes
Patient Email*
example@example.com
Patient Ethnicity:*
Patient Race:*
What COUNTY does patient live in? (Ex. Travis, Hays, Williamson, etc)*
Patient Prescription Insurance
Does the patient have health insurance?*

YES, I DO have health insuranceNO, I do NOT have health insurance (uninsured)
Please upload a picture of the FRONT of your medical and prescription cards (if separate)*

Cancelof
Please upload a picture of the BACK of your medical and prescription cards (if separate)*

Cancelof
If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)

Medicare Part A/B (Red, White, & Blue Card for patients over the age 65)Prescription Insurance (Coverage for medications at a pharmacy)Medicaid
Medicare Part B ID# (red, white, and blue card for patients over 65)*
*if you are not over 65 or do not have part B, enter "n/a".
Rx BIN#*
This information is found on your PRESCRIPTION insurance card.
Rx PCN*
This information is found on your PRESCRIPTION insurance card.
Rx GROUP ID*
This information is found on your PRESCRIPTION insurance card.
Member ID#*
This information is found on your PRESCRIPTION insurance card.
MEDICAID #:
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relation of Emergency Contact*

Acknowledgement, Consent, and Signature
PATIENT CONSENT FORM FOR COVID-19 TREATMENT PURPOSE OF INFORMED CONSENT (PAXLOVID)

As your medical provider has discussed with you, you have been diagnosed with COVID-19 (or SARS-CoV-2) or are at high risk after exposure to COVID-19. At the present time, there are few Food and Drug Administration (FDA) approved, or clinically proven therapies for treatment of COVID-19. As new clinical data emerges, local treatment guidelines have been developed and will be updated as new information becomes available. CDC guidelines reflect what is known about therapies that may work against the SARS-CoV-2 virus, have been used to treat other coronaviruses, or may theoretically target the underlying causes of virus-related severe lung conditions that make breathing difficult.

The FDA has granted Emergency Use Authorization (EUA) to permit investigational therapies in patients with confirmed or suspected COVID-19. Investigational therapies are not approved for any indication. They are authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. If checked below and signed, you consent to the use under this authorization.

TREATMENT

In order for you to be treated with the therapy by the pharmacy team, you must sign this form to show that you agree to the use of investigational or off-label treatments, and that you have been informed of the benefits and risks of taking such therapies as well as the benefits and risks of declining or refusing such use. You will be provided a patient informational handout regarding the specific antiviral before the therapy begins. You have the right to refuse to take this treatment(s) for any reason.

BACKGROUND

PAXLOVID is an investigational treatment of mild-to-moderate COVID-19 in adults and children[12 years of age and older weighing at least 88 pounds (40 kg)] with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.The FDA has issued an Emergency Use Authorization (EUA) to permit the use of this unapproved medication. Clinical trials are ongoing to study its safety and efficacy.

POSSIBLE BENEFITS

It is possible that the medication listed above may help to control your symptoms, slow or stop the growth of the virus, shorten the duration or lessen the severity of the illness in you. Possible benefits primarily include improvement in lung function (ability to breathe without assistance) and normalization of blood pressure. However, there is the possibility that this medication may be of NO direct medical benefit to you. Your condition may get worse.

POSSIBLE RISKS AND KNOWN SIDE EFFECTS

It is possible that the medication prescribed may not improve your symptoms and not shorten the duration nor severity of the illness. It is possible that the medication will unexpectedly interfere with your ability to improve, hasten damage to the lungs or other organs, and shorten your life.

List side effects/risks: dysgeusia (taste disorder), diarrhea, hypertension, myalgia (muscle pain)

Serious side effects: anaphylaxis

CERTIFICATION AND SIGNATURES

I have read this informed consent form and all of my questions have been answered to my satisfaction by my physician/pharmacy team. I understand that I have the right to refuse to take this medication(s) for any reason. If I choose not to take this medication(s), this decision will not otherwise affect my status as a patient. I voluntarily consent to take the antiviral medication as discussed with my physician and pharmacy team members as described in this consent form.

I also acknowledge that I've been provided with the electronic version of the FDA EUA information for Paxlovid.

CONSENT

The FDA has granted Emergency Use Authorization (EUA) to permit investigational therapies in patients with confirmed or suspected COVID-19. Investigational therapies are not approved for any indication. They are authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. If checked below and signed, you consent to the use under this authorization.

I have read and had explained to me the benefits versus risk of the above therapy. I am capable of making an informed decision and voluntarily grant consent, without coercion or duress to accept therapy.
I understand that PAXLOVID is NOTauthorized for pre-exposure or post-exposure prophylaxis for prevention of COVID 19.*

Yes
I understand that PAXLOVID is NOT authorized for use longer than 5 consecutive days.*

Yes
Date of Form Completion*

MonthDayYear
Date
Signature of patient or authorized person for consent and all acknowledgements: *

Clear

My Products

COVID-19 Treatment ConsultationThis is a consultation with a licensed pharmacist to determine if COVID-19 treatment is appropriate for the patient. Tarrytown Pharmacy will reach out to you via phone, during normal business hours for the consult.

$49.99

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Total

$0.00

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Consultation Acknowledgement and Agreement*

I acknowledge that this consultation is not a guarantee for treatment. Treatment depends on meeting criteria for appropriate prescribing. Payment of this consultation covers the time and resources for the medical professional. The consultation fee is non-refundable, even If treatment is not prescribed.
Payment Methods

Credit or debit cardPayPal
Should be Empty:

	Yes	No
Older age (65 years of age and older)
Obesity or being overweight (for example, adults with BMI > 25 kg/m2, or if age 12-17 have BMI >85th percentile for their age and gender on CDC growth charts: http://www.cdc.gov/growthcharts/clinical_charts.htm)
Pregnancy or recent pregnancy
Chronic Kidney Disease or Chronic Liver Disease
Diabetes (Type 1 or Type 2)
Immunosuppressive disease or immunosuppressive treatment
Cardiovascular disease (including congenital heart disease) or hypertension
Chronic lung diseases (for example, chronic obstructive pulmonary disease, moderate-to- severe asthma, interstitial lung disease, cystic fibrosis and pulmonary hypertension)
Sickle cell disease or thalassemia
Neurodevelopmental disorders (for example, cerebral palsy) or other conditions that confer medical complexity (for example, genetic or metabolic syndromes and severe congenital anomalies)
Having a medical-related technological dependence (for example, tracheostomy, gastrostomy, or positive pressure ventilation (not related to COVID-19))
Dementia
Cancer
HIV
Smoking (current or former)
Substance abuse disorder
Tuberculosis
Stroke or cerebrovascular disease
Mental health condition (mood disorder, depression, schizophrenia)

Paxlovid Treatment Request (Oral Antiviral Treatment for COVID-19)

Eligibility for Treatment

Patient Demographic Information

Patient Prescription Insurance

Emergency Contact Information

Acknowledgement, Consent, and Signature