COVID-19 Outpatient Therapeutics - Patient Eligibility Intake Form |
IMPORTANT UPDATES:Statement regarding Omicron Subvariants 11/21/22 Update: With the rapid increase in the circulation of certain SARS-CoV-2 Omicron subvariants in the United States, California, and our geographical region, the SHC COVID-19 Outpatient Therapeutics Team has decided to implement the following changes to our monoclonal antibody (mAb) therapies for the prophylaxis and treatment of COVID-19:
The COVID-19 Outpatient Therapeutics Team will continue to monitor this situation closely and provide updates. Our team will do our best to communicate information about these changes to patients. We ask for your assistance in informing your staff and patients. Thank you for your efforts in providing excellent care and evidence-based approaches to our patients.
Thank you, The SHC COVID-19 Outpatient Therapeutics Team |
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.
For questions, please email dl-shc-pharmacy-covid@stanfordhealthcare.org.