The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

PeYELiiIyyxoNADuC8ZxDVw4bBGwEBNA6jCEyW3g

This COVID-19 Patient Referral Form is for referring physician use only.

Thank you for referring your patient to VCU Health System.

We would like to inform you that Remdesivir is now approved by the FDA under an expanded use agreement.

We also have several clinical trials for COVID-19 at VCU Health System. If you would like your patient to be considered for these, we will greatly appreciate it if you can provide the following information to help us determine the best approach.

First Name

* must provide value

Last Name

* must provide value

Email Address

* must provide value

Pager

Phone Number

Patient HCO Location

Patient is at VCU Health

Patient is at other HCO

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Patient location within VCU Health

Other HCO if not at VCU Health

First Name

* must provide value

Last Name

* must provide value

Patient DOB

* must provide value

M-D-Y

Medical Record Number

Is oral temperature equal to, or greater than, 37.2 C?

Yes

reset

Provide Oral Temperature in Celsius

Was patient tested POSITIVE by PCR test for COVID-19?

Yes

reset

Date of COVID-19 Positive Test

M-D-Y

Oxygen

Not Requiring Supplemental O2

Nasal Canula

High Flow

Mechanically Ventilated

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On Pressors

Yes

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Acute Kidney Injury

Yes

reset

Abnormal LFTs >x5ULN

Yes

reset

Known or suspected concomitant bacterial or fungal infection?

Yes

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Identify the Site of Infection

Comments

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Date Entered

M-D-Y H:M

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