Infusion Referral forms

Sparrow COVID-19 IV Infusion Treatment

To qualify for treatment, patients must be defined as “high risk” for severe complications from COVID-19.

And must meet the criteria below.

  • Positive COVID-19 test result
  • Onset of symptoms within the past 10 days
  • High-risk adult patients must meet at least one of the following criteria:
    • Have a body mass index (BMI) ≥ 35
    • Have chronic kidney disease
    • Have diabetes
    • Have immunosuppressive disease
    • Are currently receiving immunosuppressive treatment
    • Are ≥ 65 years of age
    • Are ≥ 55 years of age and have
      • Cardiovascular disease, OR
      • Hypertension, OR
      • Chronic obstructive pulmonary disease/other chronic respiratory disease

To refer a patient to the clinic, submit an order, which can be found in EPIC and/or physicians can download and fax completed order form to the desired clinic location as noted on the form. 

For questions, please email