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Required format:

6jkwEWpum2rVYDUKHdZHZXa3I4tGadGqGSbQnkN3UK3mw2i2QeYDqNVnfi6RViC3wcf

Referral Form for EVUSHELD

Please do not re-enter this form for patients who need supplemental doses as of 2/28/2022.

Using tixagevimab plus cilgavimab (EVUSHELD) as SARS-CoV-2 PrEP is NOT AUTHORIZED by the FDA in unvaccinated individuals for whom COVID-19 vaccination is recommended.

No patient should be denied access to Evusheld based on disability, religion, race, ethnicity, national origin, immigration status, gender/gender identity, perceived quality of life, or sexual orientation.

Resources

Patient Name

* must provide value

MRN

Patient DOB

* must provide value

M-D-Y

Best Patient Contact Number

* must provide value

Patient's Preferred Language
Please specify only if preferred language is not English

Is this referral for the initial dose or the second dose of Evusheld?

* must provide value

Initial Dose

Second Dose

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Is the patient ≥ 12 years old and weigh at least 40 kg?

* must provide value

Yes

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Has the patient been diagnosed with COVID-19 in the last 30 days?

* must provide value

Yes

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Has the patient received SARS-CoV-2 monoclonal antibodies in the last 30 days?

* must provide value

Yes

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Has the patient received a COVID vaccine?

* must provide value

Yes

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How many vaccines has the patient received?

* must provide value

mRNA vaccine x 3

mRNA vaccine x 2

Non-mRNA vaccine x 1

Combination of non-mRNA vaccine and mRNA vaccine

mRNA vaccine x4

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Date of First Vaccine

* must provide value

M-D-Y

Date of Second Vaccine

* must provide value

M-D-Y

Date of Third Vaccine

M-D-Y

Date of Last Vaccine

M-D-Y

Reason patient is not fully vaccinated

* must provide value

Unable to be fully vaccinated with any available COVID-19 vaccines due to a documented history of severe adverse reactions to a COVID-19 vaccine or any of its components

Unable to be vaccinated because the patient is within 1 month of solid organ transplant or within 3 months of stem cell transplant

No contraindication, hasn't been completed yet

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Please optimize vaccination status for moderate to severely immunocompromised individuals prior to consideration for EVUSHELD.

* must provide value

I acknowledge

Has patient been tested for anti-spike protein IgG Covid-19 antibodies?

* must provide value

Yes

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The patient must have a negative anti-spike IgG result to qualify for EVUSHELD at this time.

* must provide value

I acknowledge

Did the patient have a negative or low anti-spike IgG at least two weeks after their last vaccine dose? For example, if the patient received their last dose on 1/1/2022, their anti-spike IgG should be tested no earlier than 1/14/2022.

* must provide value

Yes

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Date of Antibody Test

* must provide value

M-D-Y

Level

* must provide value

Prior to receiving treatment, proof of negative or low anti-spike IgG must be uploaded in Epic. I affirm that the result has been or will be uploaded to the Epic Media tab.

* must provide value

I affirm

Referring Provider Name

* must provide value

Referring Provider Phone Number

* must provide value

Referring Provider Email Address

* must provide value

Yes

Solid Organ Transplant on immunosuppression

* must provide value

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Allogenic Stem Cell Transplant or cGVHD on immunosuppression

* must provide value

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Recipient of CAR-T or BiTE Ab within 1 year

* must provide value

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Current treatment with B cell depleting therapy (rituximab, ocrelizumab, alemtuzamab) or ATG within 1 year

* must provide value

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Autologous Stem Cell Transplant within 1 year

* must provide value

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Current treatment with BTK inhibitors

* must provide value

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Multiple Myeloma on anti-BMCA or anti CD 38 treatment

* must provide value

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Acute Leukemia diagnosis within 1 year

* must provide value

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Severe primary immunodeficiency

* must provide value

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Advanced or untreated HIV infection (defined as people with HIV and CD4 T lymphocyte cell counts < 200/mm3)

* must provide value

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Year of Transplant

Yes

Is the patient at increased risk of exposure to COVID-19 by New York State's definition of an essential worker? (Link to NYS Guidance is at the top of this form)

* must provide value

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Is the patient a resident in a congregate setting, for example, long-term care facility or group home?

* must provide value

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I have reviewed the FDA Fact Sheet with the patient.
The FDA Fact Sheet link is at the top of this form

* must provide value

I affirm

I, or another member of my team, has informed the patient that they may follow-up with me (the referring provider), my designate, or another provider (e.g. patient's PCP, community health center) if needed. The Infusion Center does not provide any follow up service.

* must provide value

I affirm

I, or another member of my team, has informed the patient that they should expect a call for the scheduling of EVUSHELD if the patient meets the eligibility requirements and has been selected for treatment.

* must provide value

I affirm

The patient has attested that they are willing to receive this treatment if eligible based on the current guidelines.

* must provide value

I affirm

Completion of this form does not guarantee that the referred patient will be offered EVUSHELD.

* must provide value

I acknowledge

In the setting of supply constraints, those patients who are highest risk for progression to severe COVID-19 will be prioritized for the prescribing of EVUSHELD.

* must provide value

I acknowledge

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