COVID Therapies Referral Request

By filling out and submitting this form, the patient understands this information is for screening purposes and COVID therapy consultation ONLY and does not guarantee oral or IV therapy.

Are you a patient, caregiver or provider?
Check box if ALL of the following apply:
The patient is older than 14.
The patient has a positive COVID viral test (home tests NOT accepted).
The patient has not been seriously ill or hospitalized with COVID.
The patient's symptoms started within the past 7 days.
The patient has one of the following co-morbidities:
Comorbidities: Please check the box next to any that apply to the patient.
If you don't know your BMI, you can do an internet search to calculate.

Severe Immunocompromising Condition or Therapy

  • Patients who are within 1 year of receiving B-cell depleting therapies (e.g., rituximab, ocrelizumab, ofatumumab, alemtuzumab) 
  • Patients receiving Bruton tyrosine kinase inhibitors 
  • Chimeric antigen receptor T cell recipients 
  • Post-hematopoietic cell transplant recipients who have chronic graft versus host disease or who are taking immunosuppressive medications for another indication 
  • Patients with tumors or hematologic malignancies who are on active therapy
  • Lung transplant recipients 
  • Patients who are within 1 year of receiving a solid-organ transplant (other than lung transplant) 
  • Solid-organ transplant recipients with recent treatment for acute rejection with T or B cell depleting agents 
  • Patients with severe combined immunodeficiencies 
  • Patients with untreated HIV who have a CD4 T lymphocyte cell count <50 cells/mm3 

Patient does NOT meet qualifications

We're sorry. Based on the answers you have provided, the patient does not meet the qualifications for the COVID therapies we offer at St. Charles. If you feel you have reached this message in error, please reach out to your primary care provider to discuss.

Thank you.

Patient Vaccination Status
Patient's Full Name
Format: MM/DD/YYYY

By filling out and submitting this form, the patient understands this information is for screening purposes and COVID therapy consultation ONLY and does not guarantee oral or IV therapy.