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 12.
The patient has a positive COVID viral test (home tests NOT accepted).
The patient is not experiencing severe disease or requiring oxygen supplementation due to COVID-19.
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.
Please use the text area below to enter the patient's other comorbidities.
Please use this area to enter any comorbidities that aren't listed above.

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.

Our recommendation: Continue care at home

Most people who get COVID-19 will recover with time and home care. Here are some things to know if you're caring for someone who's sick. 

Patients with COVID-19 who are treated with medications for underlying medical conditions should not discontinue these medications during acute management of COVID-19 illness unless directed by a health care provider. 

Common symptoms include fever, coughing and feeling short of breath. Be sure to get extra rest and drink plenty of fluids to replace fluids lost from fever. 

To reduce a fever, take Acetaminophen (such as Tylenol). It may also help with muscle aches. Read and follow all instructions on the label. 

Watch for signs that the illness is getting worse 

You may need medical care if you're getting sicker (for example, if it's hard to breathe). But call your doctor's office before you go. They can tell you what to do. 

Consider contacting your primary care provider for a phone or virtual visit 

If you would like a phone or virtual visit during this time, please contact your primary care provider’s office or, if you're a St. Charles patient, visit our virtual visits page.

Call 911 or emergency services if you have any of these symptoms: 

  • Severe trouble breathing or shortness of breath
  • Constant pain or pressure in their chest
  • Confusion or trouble thinking clearly 
  • A blue tint to your lips or face