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8110 Gatehouse Road, Falls Church, VA 22042

COVID-19 Treatment Clinics Referral Form



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. Positive COVID-19 test within 10 days (required to qualify for mAb treatment)
2. Symptom onset within the past 10 days (required to qualify for mAb treatment)
3. Stable with relative hypoxia or other symptoms that don’t currently require hospitalization and is cleared for recovery at home
4. Patients 12 or older who weigh at least 40 kg who have the following risk factors

Patient Information