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Monoclonal Antibody (MCA) Therapy Request Form

For Provider Use Only

Stop!!! Important Information for referring physicianREAD THIS! Important information for referring physician

It is necessary to discuss both products with the family because we do not know day-to-day which drug we will have in stock.  Drug administration will continue to be IV, and the side effect concerns are primarily allergic reactions for both products. These fact sheets will also be downloadable from the ordering page and on the document links within Meditech.

Please still submit your requests, but advise families and patients that due to availability they may not be able to receive the infusion or that there may be a delay.


REGEN-COV




BAMLANIVIMAB and ETESEVIMAB

  • Fact Sheet for Caregivers - Emergency Use Authorization (EUA) of Bamlanivimab and EtesevimabInformation Sheet for Patients, Parents and Caregivers (English PDF | Spanish PDF)
    Fact sheet for patients, parents and caregivers. Emergency Use Authorization (EUA) of Bamlanivimab and Etesevimab for coronavirus disease 2019 (COVID-19)
  • Information Sheet for Health Care Providers (PDF)
    Fact sheet for health care providers. Emergency Use Authorization (EUA) of Bamlanivimab and Etesevimab for coronavirus disease 2019 (COVID-19)