Request COVID-19 Treatment

Patient Name (required):
Patient Phone Number (required):
Patient Email (required):
Preferred Location (required):MesaTucson

Have you tested positive for COVID-19 in the past 10 days(required):YesNo
If you are having symptoms of COVID, when did they start(required):
Has anyone in your house tested positive for COVID-19 in the past 5 days(required):YesNo
Are you moderate/severely immunosuppressed and looking for prevention treatment (ie Euvusheld)? (required):YesNo

How Many doses of any COVID-19 vaccine have you received? (required)
What was the date of your last COVID-19 vaccine? (required)
What is your age? required

Select If any of the following apply to you (required): AsthmaBMI>30Chronic kidney diseaseCurrent cancerDowns syndromeHIV with CD4 <350HypertensionImmunosuppressant medicationOrgan transplantPregnant or recent pregnancySickle cell diseaseSmokerStrokeThalassemiaType 1 DiabetesType 2 DiabetesTuberculosisNone of the Above

If you have a lung disease list here:
If you have a liver disease list here:
If you have a heart disease list here:
If you have a mental health disorder list here:
If you have a neurologic disease list here:

If you or someone in your house has COVID-19, are there any unvaccinated people living in your house without COVID-19 symptoms who may be interested in participating in clinical trials of medications for prevention of COVID-19 (required):
YesNo
Notes

Are you looking for treatment for someone under age 12 (only in clinical trials)? (required):
YesNo

How did you hear about us? (required):
ClinLifeFacebook AdsNewsTV CommercialRadioInternet AdGoogleYouTubeFamily/FriendPhysicianFlyerFax BlastOther

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