Referral to GEDI Infusion Center 2

Referral to GEDI Infusion Center
What to Expect:

Once this COVID Treatment referral is submitted, based on your patient's risk profile for progression to severe disease, they will be allocated to receive either one of our monoclonal antibodies or an oral antiviral therapy. It’s important to note that based on available data there appears to be poor invitro efficacy of regeneron or Eli Lilly monoclonal antibody for omicron, hence not recommended as a treatment option at this time for high-risk patients
Patient First Name*
Patient Last Name*
Patient Date of Birth*

MonthDayYear
Last 4 Digits of Patient Social Security Number*
Needed to confirm patient identity in electronic health record.
Patient Gender*
Patient Email Address*
Needed in order to notify patient of appointment information and referral status.
Patient Age*
Patient Height and Weight*
Patient Phone #*
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date of Symptoms*

MonthDayYear
Please answer the questions below:
Is the patient's BMI greater than or equal to 35 kg/m2 or if age 12-17years, has BMI greater than or equal to the 85th percentile for their age and gender?*

YesNo
Is the patient currently pregnant?*

YesNo
Does the patient meet person of color status?*

YesNo
How many Covid-19 vaccine doses has the patient received?*
Please select all that apply to patient*

COVID+ testSolid Organ Transplant RecipientDiabetes MellitusChronic kidney diseaseChronic liver diseaseCardiovascular diseaseChronic Respiratory diseasePediatric patient that meets eligible requirementsHypertensionSickle cell diseaseImmunocompromised
Does the patient take any medications?*

YesNo
What service is being requested? (example: Monoclonal Antibody Infusion or IV Hydration)*
Please list any medications the patient is taking. If you are currently not taking any medications, please type "N/A".*
Note: If "Yes" was selected in the prior question, you must submit a list of medications you are currently taking in order to determine appointment and treatment eligibility.
Please attach a copy of your COVID-19 Test Results*

Cancelof
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