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8110 Gatehouse Road, Falls Church, VA 22042

Evusheld Online Self-referral Form for COVID-19 Negative Patients

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Evusheld Online Self-Referral Form for COVID-19 Negative Patients

NOTICE: Treatment Criteria and Availability

Please submit the form below if you are COVID-19 negative and meet the criteria noted. Note that you will ONLY receive a call to schedule a treatment if: 1) patient meets the current eligibility criteria; and 2) we have supply available. Thank you for your understanding.

Note: Google Chrome is recommended as the optimal browser for this form. 

Patient Age and Weight
Please confirm that the patient is not currently infected with SARS-CoV-2 and has not had a known recent exposure to an individual infected with SARS-CoV-2 [within past 2 weeks?]

Risk Factors: CHECK ALL THAT APPLY

Please mark all the risk factors that currently apply to the patient requesting referral. In order to treat every patient appropriately, it is important that all relevant risk factors are noted.

Patient with one or more of the following risk factors for severe COVID-19?

Patient Information