COVID-19 MAB Patient Self-Referral Form


Instructions


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.

 

Eligibility Requirements


In order to qualify to receive this treatment, you must:
  • Have COVID-19 AND
  • You must be 12 years of age or older AND
  • Test positive for COVID-19 with symptom onset within the last 10 days, AND
  • Meet at least one of the criteria below:
    • 65 years of age or older
    • Overweight / obesity (BMI>25)
    • Pregnancy
    • Chronic kidney disease
    • Diabetes
    • Immunosuppressive disease or immunosuppressive treatment
    • Cardiovascular disease or hypertension
    • Chronic lung disease
    • Sickle cell disease
    • Neurodevelopmental disorder
    • Medical related technology dependence not related to COVID-19
You are NOT eligible for this treatment if you are:

  • Hospitalized for COVID-19
  • Requiring oxygen therapy due to COVID-19
  • Requiring an increase in your usual oxygen flow rate due to COVID-19 if you are on chronic oxygen therapy for a non-COVID-19 related medical condition
  • Allergic to any of the ingredients in the medication

 

Please make sure to enter the date fields in mm/dd/yyyy format (month first, then day, then year).
It would be best to use the calendar that pops up after you click inside a date textbox.