Paxlovid Prescription Template for Pharmacists

Submit this form by filling out all the required fields and ensuring the patient meets the criteria for Paxlovid prescription. After completion, you can email the form to the designated contacts or use drive-thru, curbside, or delivery for the patient to pick up the medication. Use the designated submission methods such as fax or online submission if provided. It is advised to double-check all information before submission to ensure compliance and avoid delays. If you encounter any issues during submission, contact the relevant support services for assistance.

Ensure the following dates are current: Positive Test Date and Symptom Onset (must be within 5 days), Renal Function date (within 12 months), and Hepatic Function date (within 12 months).

The purpose of this form is to provide pharmacists with a standardized template for prescribing Paxlovid for the treatment of mild-to-moderate COVID-19. It ensures that all necessary criteria and medical history are considered to comply with authorized use limitations. The form streamlines the prescribing process, ensuring accurate dosage instructions based on renal function and proper documentation of patient eligibility.

• 1. Patient Name: Field to enter the name of the patient receiving the prescription.
• 2. Date: Field to enter the date when the prescription is written.
• 3. Patient Address: Field to enter the address of the patient.
• 4. Patient Date of Birth: Field to enter the date of birth of the patient.
• 5. Patient Telephone Number: Field to enter the patient's contact number.
• 6. Paxlovid Tablets (Standard Dose): Section to indicate standard dose instructions for eGFR ≥60mL/min.
• 7. Paxlovid Tablets (Renal Dose): Section to indicate renal dose instructions for eGFR ≥30 to <60mL/min.
• 8. Refills: Field to indicate the number of refills allowed for the prescription.
• 9. Diagnosis: Field to indicate the diagnosis of the patient (Covid-19).
• 10. Prescriber Comments/Must Complete Below: Section for prescriber to enter additional comments and complete necessary criteria.
• 11. Meets limitations of authorized use: Checkbox to confirm if patient meets authorized use limitations for Paxlovid.
• 12. Date of Positive Test and Symptom Onset: Field to enter the date of the positive COVID-19 test and onset of symptoms.
• 13. Renal Function: Field to enter the patient's renal function results (eGFR).
• 14. Hepatic Function: Checkbox to confirm if patient's hepatic function is normal.
• 15. Full Medication List Obtained: Checkbox to confirm if a full medication list (including OTCs/herbal supplements) has been obtained.
• 16. Reviewed for potential drug interactions: Checkbox to confirm if potential drug interactions were reviewed and no dose adjustments are needed.
• 17. Paxlovid FDA EUA Fact Sheet given to patient: Checkbox to confirm if the fact sheet was given to the patient.
• 18. Inform patient to AVOID going into the pharmacy: Checkbox to confirm if the patient was informed to use Drive-Thru, Curbside, or Delivery for pick-up.
• 19. Prescribing Pharmacist: Field to enter the name of the prescribing pharmacist.
• 20. NPI or License # and Telephone: Field to enter the NPI or License number and telephone number of the prescribing pharmacist.

If you fail to submit this form, the patient may not receive the necessary Paxlovid treatment in a timely manner. This could result in delays in managing their COVID-19 symptoms and progression.

• Delayed Treatment: Failure to submit may lead to delays in administering Paxlovid, affecting the patient's recovery.
• Non-Compliance: Not submitting the form may result in non-compliance with prescribing guidelines and regulations.

• 1. Prescribing Paxlovid: Utilized for prescribing Paxlovid to patients diagnosed with COVID-19.
• 2. Documenting Patient Eligibility: Used to document the eligibility criteria and medical history of the patient.