State COVID Form - Greater Lawrence Family Health Center

Patient Self-Referral Form for Evaluation of COVID Therapeutics Treatment

PATIENTS: Complete Form Below
PROVIDERS: For REMDESIVIR orders, click HERE.

The U.S. Food and Drug Administration has issued emergency use authorization (EUA) for the following outpatient medications, listed below in order of treatment preference as recommended by the NIH.

If you are a patient with a test-confirmed COVID-19 diagnosis and you are experiencing symptoms, you may be eligible for an outpatient treatment option, based on when your symptoms started.

Preferred Therapeutics

Paxlovid: Preferred treatment for eligible patients. This is an oral treatment and it requires a prescription to the pharmacy. Fact Sheet for Patients, Parents, and Caregivers.

If you are a GLFHC patient, please fill in the information below and submit it for evaluation. The COVID Treatment team will contact a GLFHC clinician for a prescription if you qualify.

If you are not a GLFHC patient, contact your primary care providers (PCP), to review eligibility and to send a prescription if you qualify. Prescriptions may be sent to GLFHC 34 Hav Pharmacy (or a retail pharmacy of your choice that has it available). If you are unable to get a hold of your PCP, go here for a free telehealth evaluation and prescription.

Remdesivir: Remdesivir is recommended for patients who are ineligible to receive Paxlovid. Reference the Patient Information Sheet or Package Insert for more information. This medication is given as an intravenous infusion over three consecutive days. Please have your doctor fill out this form.

Alternative Therapy

Molnupiravir is an oral treatment for mild-to-moderate COVID-19 in adults who are at high risk for progression to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate.

If you are a GLFHC patient, please complete this form and the COVID Treatment team will contact a GLFHC clinician for a prescription if you qualify.

ONLY COMPLETE this form for PAXLOVID or MOLNUPIRAVIR

Name of Person Completing This Form

Relationship To Patient

Patient Name

Date Of Birth

Primary Phone

Secondary Phone

Date First COVID symptoms began

Date Tested Positive

Primary Care Provider

Are you a Massachusetts resident, a student taking courses in Massachusetts, AND/OR a patient of GLFHC?

Are you disabled?

Medical History

Current Medications

Patient Allergies

Have you received any COVID vaccinations? If so, how many?

If yes, which COVID vaccine (for example, Pfizer or Moderna) did you receive and the dates of each vaccinations?

Please select your preferred treatment options available at GLFHC

Comments

GLFHC Locations, Hours and Phone Numbers

GLFHC Pharmacy (for oral treatment options) – Located at Greater Lawrence Family Health Center
34 Haverhill St. Lawrence, MA 01841
Hours: Mon-Thu 8:30 am-9 pm; Fri 9 am-9 pm; Sat-Sun 9 am-5 pm
Phone: 978-688-1567

GLFHC Infusion Clinic (for IV treatment options) – Located at Marston Medical Center
25 Marston St, Suite 101 (1st floor) Lawrence, MA 01841
Hours: Mon-Sat 8 am to 6 pm; Sun 8 am to 5 pm
Phone: 978-722-2870

Patient Notes

Hydrate prior to appointment to assist in IV line placement. Consider drinking 2-3 glasses of water if patient has no fluid restriction.

Located at Marston Medical Center, Suite 101 on the first floor (may need to take elevator depending where you enter the building).

Total treatment and monitoring time is 1.5 hours.