Monoclonal Antibody Referral

General Inclusion Criteria

(All must be checked YES)

	Yes	No
Positive results of direct SARS-CoV-2 Testing?
Patient has mild to moderate COVID-19 Symptoms?
Patient greater than or equal to ( ≥ ) 12 years of age?
Weight is at least 40 kg?
Patient does NOT require hospitalization due to COVID-19?
Patient does NOT require oxygen therapy or an increase in baseline oxygen flow rate due to COVID-19?

ALERT

Please Note: If the answer is NO to any of the above, the patient may not meet criteria. The information will be reviewed by the clinician.

Date Positive Result?

Date of Onset?

List Symptoms:

Weight Unit Type

Weight?

Height?

Inclusion Criteria

One or more of the following

	Yes	No
Age is greater than or equal to ( ≥ ) 65
Body Mass Intex (BMI) is greater than or equal to ( ≥ ) 25 (kg/m2) OR Body Mass Intex (BMI) is 85th percentile for age and gender (≤17 Years)
Pregnancy?
Chronic Kidney Disease?
Chronic Liver Disease?
Diabetes mellitus?
Immunosupressive disease or treatment?
Cardiovascular Disease?
Hypertension?
Chronic Lung Disease?
Hemoglobinopathies (Sickle cell and Thalassemia)?
Neurodevelopmental and Neurological Disease?
Medical-related technological dependent disease?
Current or former smoker?

Patient Information:

Patient Name:

Date of Birth (mm/dd/yyyy)

Patient Mobile Number:

Patient Email Address:

Referring Provider Name:

Referring Provider Phone Number:

Referring Provider Email Address:

Allergies including nature of reaction:

Prior infusion reactions including nature of reaction:

Patient Summary: Please include patient significant past medical history and other qualifying comments/information.

Referring Provider who is completing the form uploads the last progress notes for the patient in PDF format?

For WMCHealth Providers: Check box if progress note is already in Cerner.