California COVID-19 Test-to-Treat Consultation Request Form

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This service is for healthcare professionals in California-based long-term care and skilled nursing facilities only. Please complete this form and we will respond within 1 business day.

Email *

First Name *

Last Name *

Facility/Organization Name *

Facility/Organization Zip Code *

County *

Phone Number *

Best time to reach you during Monday to Friday, except holidays. We will try our best to call you during this time. *

Profession *

Physician

Physician Assistant

Nurse Practitioner/Advanced Practice Nurse

Nurse

Pharmacist

Other:

Please provide us a brief case description (no patient identifiers)

Please provide us with your specific COVID-19 management question

A copy of your responses will be emailed to the address you provided.

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