Covid-19 Monoclonal Antibody Therapy

Name(Required)

Gender(Required)

Male

Female

DOB(Required)

Age(Required)

Address :

City

State

Zip Code

Telephone Number

Mobile Number(Required)

Email(Required)

BMI:

Height:

Weight:

Marital Status:

Primary Care Physician

Vaccination Status:

First dose**

Fully Vaccinated**

Not Vaccinated

Status Unknown

Phone

DATE OF POSITIVE TEST

Does the patient have a New or Increasing Oxygen Requirement?

Yes

No

Date of Symptom Onset:

Symptoms include : Fever, cough, sore throat, Malaise, Headache, Muscle Pain, GI Symptoms, SOB w/ exertion

**NOTE- Patient must be symptomatic to receive Monoclonal Antibody. If Symptoms have resolved, they are not eligible

Exclusion criteria

Anticipate hospital admission due to covid-19

Required oxygen therapy due to covid-19

Required an increase in baseline oxygen flow rate due to covid-19

I hereby attest to the following:

1 I have reviewed the FDA fact sheet for Patient and Caregivers Emergency Use Authorization (EUA) with Ubylee Healthcare Group.
2 I meet the requirements as defined by the FDA and CDC inclusion and exclusion criteria.
3 If no test is included, I will pay for a test from Ubylee Healthcare Group before therapy is administered
4 All of my questions have been answered to my satisfaction by Ubylee Healthcare Group. I understand that I have the right to refuse to take this medication for any reason.
5 I understand 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 an 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) of the Act, 21 U.S.C 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
6 I understand that no one has given me any guarantee about the treatment.
7 I voluntarily give Ubylee Healthcare Group my consent to receive the monoclonal antibody therapy (mAb). I understand my personal, demographic, and health information may be reported to my healthcare provider, FDA, or CDC.
8 By signing below, I give my full consent to the use under this authorization:8. By signing below, I give my full consent to the use under this authorization:

Patient Name:(Required)

Patient Signature:(Required)

Covid-19 Monoclonal Antibody Therapy

Ubylee Healthcare Group is pleased to offer COVID-19 Monoclonal Antibody Therapy to Patients in Charlotte, North Carolina, and surrounding areas.

Please contact Ubylee Healthcare Group for Referral and Scheduling of COVID-19 Monoclonal Antibody Therapy.