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8110 Gatehouse Road, Falls Church, VA 22042

Monoclonal Antibody Treatment for Symptomatic Patients

Patient Self-Referral Form | COVID-19 Treatment Clinics
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Monoclonal Antibody Treatment for Symptomatic Patients

Patients, please complete the following form to submit a 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

You are a candidate for monoclonal antibody treatment if the following apply to you:

1. Patient >= 40 kg and >= 12 years of age with symptomatic laboratory confirmed COVID via rapid or PCR testing.
2. Illness onset within the past 10 days?
3. Patient with one or more of the following risk factors for severe COVID-19?*

Please complete the form below and you will receive a call from our EC3 for a telemedicine assessment by a provider who will discuss monoclonal antibody treatment with you and schedule you for infusion if appropriate.

Please bring a copy of your COVID-19 test results with you if an infusion is scheduled and your test was done outside of Inova.

Patient Information (Parents, if you are referring a child please enter your contact information in the first section)