BCCFH COVID Task Force Outpatient mAb Infusion for COVID Treatment

HIPAA COMPLIANT FORM * Items are mandatory

Thak you for your interest in referring your patient to the BCCFH COVID Task Force Infusion Center. This referral form has been retired. Please use the link below to redirect to our current active referral form. https://app.smartsheet.com/b/form/060655bc7b48495ca5045f5e089f87e4

Sex - other:

Patient Race - Other:*

Language - other:*

Type of SARS-CoV2 test*

PCR

Rapid Antigen

Home Rapid Antigen

Unsure

Symptoms - other:*

Is this patient's baseline O2 sat normally < 92%?

Yes

Unsure

Oxygen saturation results obtained on:*

Room air

Chronic O2 therapy

New O2 therapy

O2 flow above chronic baseline O2 flow

Baseline O2 flow rate (L/min):

New O2 flow rate (L/min):

Explain details of COVID hospitalization, including dates if known:

Close Contact is defined by the CDC as 15 minutes over the course of one hour, spent within 6 feet of someone who is confirmed COVID positive. A patient can be offered PEP if s/he has had such an exposure or is at high risk of such exposure due to the presence of a COVID-19+ individual in the same institutional setting. Additionally, in order to be offered PEP, the patient must either be unvaccinated or incompletely vaccinated against COVID-19 or must have an immunosuppressive condition, or be in treatment with an immunosuppressive medication, such that s/he would not be expected to mount a full response to the COVID vaccine. For more information, please visit https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/appendix.html#contact Regeneron for PEP is not known to be of benefit if given more than 7 days after exposure.

Describe the type of exposure.*

Patient lives with the COVID+ person.

Patient lives in an institutional setting (nursing home, prison, group home, etc.) which has had one or more COVID+ dweller.

Patient works with the COVID+ person

Other

If other, please explain*

Has the patient developed COVID symptoms since the exposure?*

Yes

Please note start date of patient's symptoms

Has the patient had a COVID test since exposure?*

Yes, the patient has been tested but resulted negative.

No, the patient has not had a COVID test since exposure.

Yes, the patient has been tested but results are pending.

If "other" please explain*

Date of most recent dose of patient's initial vaccine series.*

Date of booster dose:*

Height (inches only)*

Please convert into inches: Examples 5ft=60 inches, 5'1" = 60 + 1 = 61 inches 6' = 72 inches, and 6' 1" = 72 + 1 = 73 inches

Select

Enter the patient's weight in pounds.*

CKD Disease Stage:

Baseline [Cr]:

Specify Immunosuppressive Condition:*

Select or enter value

Other specified immunosuppressive condition:*

Specify Immunosuppressive Treatment:*

Select or enter value

Other immunosuppressive medication*

Specify Cardiovascular Disease:*

Specify congenital or acquired heart condition:*

Specify Chronic Respiratory Disease:*

Specify disorder/condition:*

Specify medical-related technological dependence:*

Privacy Notice|Report Abuse