COVID-19 MAB Patient Self-Referral Form
Please complete this form to be screened for monoclonal antibody treatment (MAB). The eligibility requirements are listed below. Straub Medical Center reserves the right to select the monoclonal antibody and route of administration (intravenous or subcutaneous) based on medication supply and clinical information available at the time of the referral.
A team member will review your response and contact you via phone or email within 24-48 hours to request additional information, if necessary, and to discuss appropriateness of the monoclonal antibody administration.
For questions, please call 632-2811 Monday through Friday between 6:30 a.m. and 3:30 p.m. Any calls received after hours will be returned on the next business day.
In order to qualify to receive this treatment, you must:
You are NOT eligible for this treatment if you are:
It would be best to use the calendar that pops up after you click inside a date textbox.