IMPORTANT UPDATES:

  • This referral form may be used to request Paxlovid, remdesivir, or bebtelovimab.
  • 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 in order of preference is Paxlovid (nirmatrelvir-ritonavir) or remdesivir. If neither of the preferred therapies are available, feasible to use, or clinically appropriate, bebtelovimab may be considered as an alternative therapy.
  • For patients who may not be eligible for Paxlovid, this referral form may also be used to request remdesivir or bebtelovimab.
  • For additional information regarding availability of COVID-19 oral antivirals, i.e. Paxlovid, in Santa Clara County, please visit the following link.
  • 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 or submit a referral here.

Do NOT submit this form for hospitalized patients or compassionate use requests.

Do not leave anything blank. To ensure clinical eligibility, available drug supply, and appointment capacity, our current process requires that all requests be reviewed and approved by a clinical team member. Upon receipt of the pertinent clinical information, you will receive a response via email within 24-48 hours about approval status and possible next steps.

SHC reserves the right to select the infusion therapy based on medication supply and clinical data available at the time of the referral. The general Monoclonal Antibody Fact Sheet for Patients, Parents, and Caregivers compiled by SHC from the FDA Fact Sheets is available in English Spanish, Vietnamese, Portuguese, Tongan, Samoan, Simplified Chinese, and Traditional Chinese.

For questions, please email dl-shc-pharmacy-covid@stanfordhealthcare.org.

 

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