IMPORTANT UPDATES:

  • Due to high rates of local transmission of the BA.2 varian (Omicron subvariant), national guidelines for treatment of COVID-19 in non-hospitalized patients have been updated. As of 3/30/22, the preferred therapy is Paxlovid (nirmatrelvir-ritonavir).
  • This referral form may be used to request Paxlovid, remdesivir, or bebtelovimab.
  • This referral form is not intended for pre-exposure prophylaxis with Evusheld. Please refer to the Stanford Health Care COVID-19 Monoclonal Antibody website for current information.

Instructions

Please complete this form to be screened for outpatient COVID-19 treatment. Refer to the eligibility requirements listed below. Stanford Health Care reserves the right to select the specific treatment based on medication supply and clinical information available at the time of the referral.

A team member will review your response and contact you via phone or email within 24-48 hours to request additional information, if necessary, and to discuss appropriateness of infusion.

For questions, please call (650) 391-8503 on Monday through Friday between 8:00 am PST and 4:30 pm PST. Any calls received after hours will be returned on the next business day. You may also email us at DL-SHC-Pharmacy-COVID@stanfordhealthcare.org.

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