Patient Name
Format: MM/DD/YYYY
Is the patient on supplemental oxygen or oxygen therapy due to COVID-19?

Patients who require oxygen therapy due to COVID-19, or patients on chronic oxygen therapy due to an underlying non-COVID-19-related comorbidity and who require an increase in oxygen flow rate from baseline because of COVID-19, are not eligible for Monoclonal Antibody Therapy.

Check here if the patient meets four of the five criteria
> 14 years of age (at least 40kg)
Positive direct COVID-19 viral test
High risk for progressing to severe COVID-19 illness or hospitalization
Within 10 days of symptom onset
Post exposure to a COVID-19 positive patient with high risk of progression to severe COVID-19
Does the patient have any of the following conditions (check all that apply)?
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