1st Part Eligibility Requirements

In order to qualify to receive this treatment, you must fall under one of the following two categories:

You must be over 18 years old, test positive for COVID-19 with symptom onset within the last 10 days.
You must be over 18 years old, test negative for COVID-19, not fully vaccinated (or immunocompromised), have exposure to an infected individual (or reside in an institutional setting).

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-related medical condition
Allergic to any of the ingredients in the medication

Please indicate your reason for submitting this self-referral:*

Please select all of the symptoms that you are expecting from the following list:*

On what date was your COVID test performed?*

Please list any medications that you are currently taking. If non, state N/A*

Name*

FirstLast

Date of Birth*

Age*

Allergies*

Height (feet, inches)*

Weight (pounds)*

Phone Number*

Address*

Street Address

Address Line 2

CityState / Province / Region

Postal / Zip CodeCountry

Email

Race*

Gender*

FemaleMale

Ordering Physician*

Insurance Provider*

Member ID/Policy Number*

Group Number (if applicable)

By completing this form you agree that you consent to receiving the vaccination and are eligible.

Please verify that you are human*

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2nd Part: Questionnaire