Skip to main content

8110 Gatehouse Road, Falls Church, VA 22042

COVID-19 Treatment Clinics Self-Referral Form

Translate

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:

Patients eligible must have experienced symptom onset within the past 10 days, have a positive COVID test, and also meet the following criteria:

Patients 12 or older who weigh at least 40 kg who have the following risk factors:

  • Older age (>=65)
  • Obesity with a BMI of >=25 for adults or BMI >= 85th percentile for children age 12-17
  • Pregnancy
  • Chronic kidney disease
  • Diabetes
  • Immunosuppressive disease or on immunosuppressive treatment
  • Cardiovascular disease, including congenital heart disease or hypertension
  • Chronic lung disease, including, but not limited to, asthma and COPD
  • Sickle cell disease
  • Neurodevelopmental disorders (i.e. cerebral palsy) or other conditions that confer medical complexity, such as genetic or metabolic syndromes and severe congenital abnormalities
  • Having a medical related technological dependence, i.e. tracheostomy, gastrostomy, or positive pressure ventilation
  • Presence of other medical or non-medical risk factors, including race or ethnicity, that may also confer high risk for severe disease.

Please complete the form below and you will recieve 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)

Patient Age Group