№ files_lp_3_process_7_089214
Structured form used for healthcare providers to refer patients with mild COVID-19 at high risk for progression to monoclonal antibody treatment under Health Canada’s interim authorization.
Year: 2026
Region / City: Canada, multiple cities
Subject: COVID-19 treatment eligibility
Document Type: Medical referral form
Organization / Institution: Health Canada; regional hospitals
Author: Clinicians completing referral
Target Audience: Healthcare providers and eligible patients
Eligibility Criteria: Adults and pediatric patients ≥12 years, ≥40 kg, at high risk of severe COVID-19
Treatment Window: Within 7 days of symptom onset
Authorization: Interim authorization (Interim Order) by Health Canada
Patient Data Fields: Name, Date of birth, Allergies, Address, Contact information, Health Card Number
Clinical Criteria: Symptomatic status, vaccination status, comorbidities, immunosuppression, prior COVID-19 infection
Referral Confirmation: Clinician attestation with signature, date, and College number
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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