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8110 Gatehouse Road, Falls Church, VA 22042

Monoclonal Antibody Treatment for Symptomatic Patients

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

Providers, please complete the following checklist to determine if your patient is eligible for a referral. All fields marked with an * are required.

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

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

Patient Information