COVID-19 assessment for antivirals		

This information can help you get the care you need if you test positive to COVID-19. Show this information to healthcare workers so they can help you get the right testing and treatment for you.

Date	<FormattedDate>	
Clinic name	<Practice>	
Clinic address	<DrStreet>, <DrCity>, <DrState>, <DrPostcode>	
Clinic contact number	<UsrPhone>	
Usual GP	<Usual GP>	

This COVID-19 treatment plan is for:

Family name	<PtSurname>	
Given name	<PtFirstName>	
Date of birth	<PtDoB>	
Home address	<PtStreet>, <PtCity>, <PtState>, <PtPostcode>	
Contact number	(home) <PtPhoneH>	(mobile) <PtPhoneMob>	

Goal of plan:

Early treatment of COVID-19 with oral antivirals to prevent serious disease	

I have the following medical conditions:

<SelectedPMH>	

My medications are:

<SelectedRx>	

I have had <I have had x number of COVID vaccines> COVID vaccines
I have a RAT test at home and know when to test early and when to get a PCR	<I have a RAT test at home and know when to test early and when to get a PCR> 
I know to phone early for a COVID treatment appointment with my doctor 	 <I know to phone early for a COVID treatment appointment with my doctor> 
I have discussed with my doctor and I am <I have discussed with my doctor and am/ am not eligible for GP prescribed GP prescribed COVID antiviral medication> for GP prescribed COVID antiviral medication
My eGFR is (result) on (date): <My eGFR is (result) on (date)>
The medication suitable for me is: <The medication suitable for me is>
The pharmacy where I can fill my  prescription is: <The pharmacy where i can fill my prescription is>
The adjustments I have to make while taking my COVID antiviral medication are: <The adjustments I have to make while taking my COVID antiviral medication are>	

Copy of Plan offered to patient? <Copy of Plan offered to patient?>
Copy/ relevant parts of the Plan supplied to other providers? <Copy/ relevant parts of the Plan supplied to other providers?>
Plan added to the patient's record? <Plan added to the patient's record?>
Date service was completed: <Date service was completed:>		Proposed review date: <Proposed review date:>
I have explained the steps and costs involved, and the patient has agreed to proceed with the service: <I have explained the steps and costs involved, and the patient has agreed to proceed with the service:>	

GP signature		GP name	<DrName>	
Date	<GP signature Date>