Skip to main content

8110 Gatehouse Road, Falls Church, VA 22042

Extended COVID-19 Care 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:

For Adults Age 18 or Older:

  • Age 65 or older
  • Age 55 or older with hypertension, heart disease, or chronic lung disease including asthma or COPD
  • If you have diabetes
  • If you are immune suppressed due to a medical condition or medications
  • If you have chronic kidney disease or end-stage renal disease

For Children Age 12-17 (must be a minimum of 40 kg):

  • Body mass index greater than or equal to the 85th percentile (calculator 1 and calculator 2)
  • Sickle cell disease
  • Congenital or acquired heart disease
  • Neurodevelopmental disorders (eg, cerebral palsy)
  • Medical-related technological dependence (eg, tracheostomy, gastrostomy, or positive pressure ventilation unrelated to COVID-19)
  • Chronic respiratory disease that requires daily medication for control (eg, asthma, reactive airway disease)

You are not a candidate if you are requiring new supplemental oxygen or an increase in your supplemental oxygen above your baseline.

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