Monoclonal Antibody Treatment & Consent Form
Been to a Medhelp Location in last 2 years
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Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Gender
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Phone Number
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Area Code
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Email
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example@example.com
Address
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Street Address
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City
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Preferred Infusion Location
Pelham - 3143 Pelham Parkway
Lakeshore - 1 W Lakeshore Drive
280 - 4600 Highway 280
Narrows - 151 Narrows Parkway
Trussville - 5915 Chalkville Mountain Rd
Samford Student Health Center - 800 Lakeshore Drive
COVID 19 History
Prior Infection of COVID 19
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Primary Insurance
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If your insurance plan requires a referral you are responsible for obtaining that within the allotted time frame.
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Self Pay
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We do not accept Medicaid or Bright Health Insurance plans.
Do you have a positive PCR Test for Covid 19 in the last 10 days?
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What date was the test?
Picture of the Test result
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Select Things that Qualify you for Monoclonal Antibody Therapy
Are older in age (e.g., age > 65 years of age).
Kidney Disease
COPD
Are overweight (e.g., adults with BMI >25)
Immune System Dysfunction
Have cardiovascular disease or hypertension
Type 1 or Type 2 Diabetes Mellitus
Pregnant
Other
PAST MEDICAL HISTORY Do you have any other chronic medical conditions (in addition to those above)?
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Please list any chronic medical conditions you have
Do you have any medication allergies?
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Please list any drug allergies you may have
Are you currently taking any medication?
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Please list any prescription or OTC medications or supplements you take regularly
PATIENT CONSENT FORM FOR COVID-19 TREATMENT PURPOSE OF INFORMED CONSENT Casirivimab/Imdevimab (Regeneron) As your physician has discussed with you, you have been diagnosed with COVID-19 (or SARS-CoV-2). At the present time, there are few Food and Drug Administration (FDA) approved, or clinically proven therapies for treatment of COVID-19. As new clinical data emerges, local treatment guidelines have been developed and will be updated as new information becomes available. CDC guidelines reflect what is known about therapies that may work against the SARS-CoV-2 virus, have been used to treat other coronaviruses, or may theoretically target the underlying causes of virus- related severe lung conditions that make breathing difficult. The FDA has granted Emergency Use Authorization (EUA) to permit investigational therapies in patients with confirmed or suspected COVID-19. Investigational therapies are not approved for any indication. They are authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. If checked below and signed, you consent to the use under this authorization TREATMENT In order for you to be treated with the therapy by MedHelp Clinics, you must sign this form to show that you agree to the use of investigational or off label treatments, that you have been informed of the benefits and risks of taking such therapies as well as the benefits and risks of declining or refusing such use. Signature:
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