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	<<Miscellaneous:Date>>	
Clinic name	<<Practice/Location:Name>>	
Clinic address	<<Doctor:Address Line 1>>, <<Doctor:City>>, <<Doctor:State>>, <<Doctor:Postcode>>	
Clinic contact number	<<Doctor:Phone>>	
Usual GP	<<Usual GP>>	

This COVID-19 treatment plan is for:

Family name	<<Patient Demographics:Surname>>	
Given name	<<Patient Demographics:First Name>>	
Date of birth	<<Patient Demographics:DOB>>	
Home address	<<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
Contact number	(home) <<Patient Demographics:Phone (Home)>>   (mobile) <<Patient Demographics:Phone (Mobile)>>	

Goal of plan:

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

I have the following medical conditions:

<<Clinical Details:History List>>	

My medications are:

<<Clinical Details:Medication List>>	

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 >>
I know to phone early for a COVID treatment appointment with my doctor	<<I know to phone early for a COVID treatment appt>>
I have discussed with my doctor and I am <<I am eligble/not for GP Prescribed COVID anitiviral >> 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 anti COVID medication are: <<Adjustments I must take while on COVID antiviral>>	

Copy of Plan offered to patient? <<Copy of Plan offered to patient?>>
Copy/ relevant parts of the Plan supplied to other providers? <<Copy/ 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: <<Explained steps/costs involved, patient has agreed>>	

GP signature		GP name	<<Doctor:Name>>	
Date	<<GP signature Date>>