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8110 Gatehouse Road, Falls Church, VA 22042

Monoclonal Antibody Treatment for Post Exposure Prophylaxis

Patient Self-Referral Form | COVID-19 Treatment Clinics
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Monoclonal Antibody Treatment For Post Exposure Prophylaxis

Patients, please complete the following form to submit a self-referral. All fields marked with an * are required.

Note: If you are a provider and want to submit a referral for a patient, use this form

1. Patient >= 40 kg and >= 12 years of age with symptomatic laboratory confirmed COVID via rapid or PCR testing?
2. Patient has been exposed to an individual infected with COVID-19 consistent with close contact criteria per CDC?

3. One of the following needs to be met:

Patient is fully vaccinated but not expected to mount an adequate immune response due to an immunosuppressive illness or immunosuppressive medication?

OR

Patient is not fully vaccinated but has one or more of these risk factors for severe COVID-19?

Patient Information

Patients will be contacted by Inova for a telemedicine consult and scheduling. For assistance please call 571-472-4502.