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.