COVID -19 Therapeutics Interest Form

Please submit interest form

Per the CDPH, the state is expecting to receive the new COVID-19 Therapeutic Treatments following FDA EUA approval. Limited quantities will be allocated for LHD. Submitting this form will assist us in the preparation and allocation of treatments. Completion of this form does not guarantee that your facility will receive a Therapeutics allocation.

Facility Information

Organization Name*

Street Address*

City*

Zip Code*

Point of Contact Information

POC First and Last Name*

POC Phone Number*

POC Email*

Therapeutic Treatment Request

We are currently not accepting the quantity of treatments that you are interested in receiving as we are awaiting official allocations and instruction for distribution from CDPH. Upon completion of the interest form, a team member will reach out to the provided point of contact to confirm quantities, orders, and delivery dates when the treatments becomes available.

Therapeutics Type(s) of Interest*

Select all that apply.

Select or enter value

Oral Anti-Viral Treatments

Select all that apply.

Select or enter value

Pre-Exposure Prophylaxis (PrEP) Treatments

Select or enter value

Additional Comments

Monoclonal Antibody (mAb) Treatments

Currently available for request at https://app.smartsheet.com/b/form/44be0979a988491ea79175050066428f Available Treatments: - Bam/Ete - Regen-COV - Sotrovimab

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