Paxlovid Provider Information Request
Please fill out the following information for every Paxlovid prescription being sent to ___ Pharmacy. ___ Pharmacy will NOT fill a prescription for Paxlovid without this information. This document and other supporting information may be faxed to ________
Patient Name: ________________________________ DOB: _________________
1. Please indicate date of positive COVID-19 test: ___________________
2. Please indicate date of symptom onset: ___________________
(Note that asymptomatic patients are not indicated for Paxlovid. Symptom onset must be within 5 days.)
3. Please indicate any conditions or comorbidities that put this patient at high-risk for progressing to severe COVID-19: _____________________________________________
(Note that patients must have one or more high-risk conditions to be indicated for Paxlovid. This can be found on the CDC’s website at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html)
4. Please indicate the patient’s most recent eGFR: _____________
5. Please provide a medication list in the table below. This can be written OR faxed to Cook’sPharmacy along with this sheet.
Medication List
6. Please indicate information or counseling you provided to the patient regarding any drug-drug interactions and potential medication therapy adjustments (ie. temporarily holding any medications, dose adjustments, etc.)
Please feel free to reach out with any questions or concerns at _________
Thank you!