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8110 Gatehouse Road, Falls Church, VA 22042

Extended COVID-19 Care Clinics Referral Form

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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. 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. Adult ≥ 18 , > 40 kg with one of the following risk factors (will need at least one to qualify for mAb treatment)
5. Child age 12-17, > 40 kg, with one of the following risk factors (will need at least one to qualify for mAb treatment)

Patient Information