Monoclonal Antibodies Monoclonal Antibody Monoclonal Antibody Registration Last Name * First Name * Date of birth * Sex * M F Unknown Street Address City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming - Puerto Rico Virgin Islands Zipcode * FL County Of Residence * ALACHUA BAKER BAY BRADFORD BREVARD BROWARD CALHOUN CHARLOTTE CITRUS CLAY COLLIER COLUMBIA DADE DESOTO DIXIE DUVAL ESCAMBIA FLAGLER FRANKLIN GADSDEN GILCHRIST GLADES GULF HAMILTON HARDEE HENDRY HERNANDO HIGHLANDS HILLSBOROUGH HOLMES INDIAN RIVER JACKSON JEFFERSON LAFAYETTE LAKE LEE LEON LEVY LIBERTY MADISON MANATEE MARION MARTIN MONROE NASSAU OKALOOSA OKEECHOBEE ORANGE OSCEOLA PALM BEACH PASCO PINELLAS POLK PUTNAM SANTA ROSA SARASOTA SEMINOLE ST. JOHNS ST. LUCIE SUMTER SUWANNEE TAYLOR UNION UNKNOWN VOLUSIA WAKULLA WALTON WASHINGTON OUT-OF-STATE Phone Email Race * BLACK WHITE ASIANIND ASIANOTH OTHER UNKNOWN Are you Hispanic or Latino? * Y N Unknown Are you 12 or older? * Yes No LEGAL GUARDIAN INFORMATION If under 18 years old Name Name Name Name Upload Drivers License (Front Side) Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload Drivers License (Back Side) Drop a file here or click to upload Choose File Maximum upload size: 516MB PATIENT SCREENING QUESTIONS Please check YES or NO for each question. Are you moderate to severely immunocompromised and registering for Evusheld? * No Yes If yes, name and phone number of your primary care physician are required to confirm eligibility. Primary care physician name * Primary care physician phone * Have you tested positive for and/or been diagnosed with COVID-19 infection within the last 10 days? * No YesYes If yes, what was the date of your positive test or diagnosis? What symptoms have you been experiencing? 2. Have you been exposed to someone with known COVID-19? * No YesYes If yes, what was the date of this exposure? 3. Have you had any COVID-10 antibody therapy within the last 28 days (for example, Sotrovimab, Bebtelovimab, REGEN-COV, bamlanivimab and etesevimab, COVID-19 convalescent plasma, etc.)? * No Yes 4. Are you 65 years of age or older? * No Yes 5. Are you overweight or have you been diagnosed with obesity? * No Yes 6. Are you pregnant? * No Yes 7. Do you have any one or more of the following medical risk factors kidney disease, diabetes, cardiovascular disease, congenital heart disease, hypertension, chronic lung disease, sickle cell disease, immunosuppressive disease, undergoing immunosuppressant treatment or taking immunosuppressant medication, Neurodevelopmental disorder, cerebral palsy, genetic or metabolic syndromes, medically related technological dependence such as tracheostomy gastrostomy or positive pressure ventilation? * No Yes Do you have any other high-risk conditions not already specified above? * No YesYes CONSENT STATEMENTS FROM PATIENT I certify that I am (a) the patient and at least 12 years of age (b) the legal guardian of the patient and confirm that the patient is at least 12 years of age or (c) legally authorized to consent for administration of Sotrovimab, Bebtelovimab, or other monoclonal antibodies for the patient named above. Further, I hereby give my consent to the Florida Department of health (DOH) or its agents to administer Bebtelovimab or other monoclonal antibodies to me or to the patient named above. I understand that this product has not been approved or licensed by the FDA, but has been authorized for the emergency use by the FDA, under a EUA for the treatment of mild or moderate coronavirus disease 2019 (COVID-19), and for post exposure prophylaxis of COVID-19, in adult and pediatric patients 12 years of age and older weighing at least 40 kg with positive results of direct SARS–COV–2 viral testing, and/or known exposure to a household contact diagnosed with positive SARS–COV–2 viral test, and who are at higher risk of progression to severe COVID-19 including hospitalization and death. The emergency use of this product is only authorize for the duration of the declaration that circumstances exist justifying the authorization of emergency use of the medical product under (Section 564) of the FD&C act unless the declaration is terminated or authorization revoked sooner. I understand that it is not possible to predict all possible side effects or complications associated with receiving this treatment. I understand the risks and benefits associated with above treatment and have received, read and/or had explained to me the emergency use authorization fact sheet. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I acknowledge that I have been advised to remain at the treatment location during administration of Bebtelovimab or other monoclonal antibodies and for at least one hour after completion of either intravenous infusion or subcutaneous injections, or as directed for observation. If I experienced a severe reaction, I will call 911 or go to the nearest hospital. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the state of Florida, the Florida Department of health DOH, the Florida division of emergency management FDEM, and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities are claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the treatment listed above. I further authorize DOH, FDEM, or its agents to submit a claim to my primary insurance carrier identified above on my behalf or on behalf of the patient named above for the administration of Bebtelovimab or other monoclonal antibodies. I assign and request payment of authorize benefits to be made on my behalf to the DOH, FDEM, or its agents with respect to the administration of Bebtelovimab or other monoclonal antibodies. I understand that any payment for which I am financially responsible is due at the time of service or if DOH invoices me after the time of service, upon receipt of such an invoice. I acknowledge receipt of the DOH notice of privacy practices and the fact sheet for patients, parents and caregivers. INSURANCE DO YOU HAVE INSURANCE? * Yes No Which insurance do you have? Medicaid Medicare Florida Blue Other Which insurance do you have? Upload a copy of the FRONT of your insurance card. Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload a copy of the BACK of your insurance card. Drop a file here or click to upload Choose File Maximum upload size: 516MB Upload a copy of your ID (license, passport) Drop a file here or click to upload Choose File Maximum upload size: 516MB INSURANCE Policy # Group # Type of Plan? HMO PPO Non PPO Name of Insured Effective Date Phone Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country THIS SECTION IS TO BE COMPLETED BY ADMINISTRATION. Treatment used? -- BEBTELOVIMAB SOTROVIMAB CASIRIVIMAB & IMDEVIMAB ETESEVIMAB EVUSHELD Lot # Lot # Lot # Lot # Date Date Date Date Vaccine Administering Provider Suffix: If you are human, leave this field blank. Submit ADMINISTRATION LOGIN
