Author: Jacinta Nagle
Last saved by: Yelena Minasyan
Company: SA Health
Category: Confidentiality, I#,A#

OFFICIAL: Sensitive//Medical in confidence (when completed)

National Medical Stockpile COVID-19 Treatment Referral Form
This Referral Form is for use by medical practitioners referring COVID-19 positive adult patients to SA Health for consideration of treatment with available medicines from the Commonwealth's National Medical Stockpile (NMS) for the early intervention of COVID-19.
Note: Completed referrals must be submitted via SA Health's COVID-19 Outpatient Treatment Referral portal ONLY; referrals sent outside of the portal (e.g. email) will NOT be actioned. 
Note: Patients eligible for PBS access to oral antiviral therapy who are clinically appropriate for treatment with oral medication should NOT be referred via this pathway, except where needing specific consideration of NMS treatments not available via PBS (e.g. remdesivir or monoclonal antibody infusions). See the SA Health COVID-19 outpatient treatment guidelines for NMS COVID-19 treatment eligibility. 
EXCLUSION CRITERIA: The following patients should NOT be referred for treatment using this form:
•	Patients who are eligible for PBS supply of oral antiviral treatment AND who are clinically appropriate for treatment with oral medication,
•	Patients under 18 years of age (for children who may require COVID-19 treatment, please discuss with the COVIDKids service at the Women's and Children's Hospital), or
•	Patients with a new or increased oxygen requirement.  (Note: patients who are ordinarily on oxygen and do not have an increased need ARE eligible for referral).
Dedicated Medical Advice Phone Line for COVID Community Response: 1800 313 090, 8am-8pm, 7 days.  This phone line is for CLINICIAN USE ONLY, patients should NOT be calling this number. The Clinician Medical Advice phone line is available to support GPs and other medical specialists with COVID-19 management in the community, including advice regarding prescription of oral antiviral medications.
Referrer Details
Name: | Treating Doctor.Name
Prescriber Number: | Treating Doctor.Prescriber Number
Date: | Miscellaneous.Date
Contact phone:  Treating Doctor.Phone | Email: Treating Doctor.E-mail

Practice name and address:

Practice.Name
Practice.Address
Practice.Phone

Name and contact details for patient's usual GP: 
(if not the same as above)

Patient Details
First Name: Patient Demographics.First Name | Surname: Patient Demographics.Surname
Date of Birth: Patient Demographics.DOB | Age (must be 18 or over):  Patient Demographics.Age
Gender: | Patient Demographics.Gender
Person identifies as: | Patient Demographics.ATSI Status
Interpreter required?  Interpreter Required | if Yes, Language: Language
Medicare number: Patient Demographics.Medicare Number
Non-Medicare / Medicare ineligible | Reason: Reason

Home address: 
Patient Demographics.Full Address

Isolation address (if different to home):

Mobile Number: 
Patient Demographics.Phone (Mobile)

Landline Number: 
Patient Demographics.Phone (Home)

Patient's Carer/Guardian/Substitute Decision Maker (if applicable)
Name: | Patient Demographics.NOK Name
Relationship to Patient: | Patient Demographics.NOK Relationship
Contact number: | Patient Demographics.NOK Mobile Phone
Interpreter required? NOK Interpreter | if Yes, Language: Language NOK
Eligibility Details
Is the patient eligible for PBS access to oral antiviral medications (Paxlovid^®, Lagevrio^®)? | PBS access

If Yes, provide details on why this patient needs access to NMS medicines:
NMS Medicine Reason

Positive COVID-19 test: | Date of positive COVID-19 test collection: COVID Test Date
| Type of COVID-19 test: | Test Type
Is the patient symptomatic? | Symptomatic | if Yes, date of symptom onset:symptom onset
| | if No, ensure PCR test is collected as soon as possible.
Current day of illness: Day of Illness | Where Day 0 is the day of positive test collection or day of symptom onset, whichever is earlier.
Has the patient previously received any antiviral or monoclonal antibody medication for COVID-19? | Previous medication

If Yes, please provide treatment details including medicine, dose and date commenced:
Treatment details

How many doses of COVID-19 vaccine has the patient received? Vaccines doses
What was the date of the last COVID-19 vaccine dose? Last dose date
Is the patient considered up-to-date* with COVID-19 vaccination status? | Vaccine Status
* Definition of not up to date vaccine status: Unvaccinated OR single dose vaccination OR less than 2 weeks since primary course of COVID-19 vaccination OR less than 7 days since any booster vaccination OR ≥ 3 months since primary COVID-19 vaccination course with no booster vaccination. Refer to ATAGI for more information on booster doses and definition of up to date vaccine status.

Is the patient immunocompromised as per 
SA Health criteria defined here?

Immunocompromised

If Yes, provide details (including all immunosuppressive medications and doses if applicable):
Immunosuppressive

Does the patient have risk factors for progressing to 
severe or critical illness as defined by SA Health here?

Risk factors

If Yes, provide details of ALL risk factors:
Risk Factors explain

Specific Treatment Considerations

Is the patient pregnant?

Pregnant

if Yes, current gestation: 
Pregnancy.Gestational Age

| | if No, please consider pregnancy test prior to treatment for appropriate patients.
Patient weight (kg): | Current Measurements.Physical - Weight
What is the patient's relevant past medical history? | Clinical Details.Past History
What medications (including doses) is the patient currently taking? | Clinical Details.Medications - Current Regular
What over-the-counter supplements, medications, complementary medicines or recreational drugs is the patient currently using? | Other medication

What is the patient's 
most recent (in the last 6 months) eGFR?

| Patients eGFR

Does the patient have severe hepatic impairment?
(Child-Pugh Class C)

Hepatic Impairment

Are any COVID-19 antiviral treatments specifically contraindicated in this patient? 
See Prescriber Information here.

Contraindicated

If Yes, provide details: 
Contraindicated note

Does the patient have any difficulties with swallowing tablets, managing medications independently or with IV access? | Medication Difficult

If Yes, provide details: 
Difficulties details

Other relevant clinical information regarding this referral:

Clinical Details.Selected Most Recent Measures

Clinical Details.Problem List (Current)

Extra Clinical Data.Referrals List

Relevant info