Nirsevimab Eligibility and Approval Request Form

Patient Full Name

First NameLast Name

Patient Date of Birth

Date

Patient Sex

Other

Patient Weight (kg)

Gestational Age at Birth (weeks)

Relevant Medical History (e.g., chronic lung disease, congenital heart disease, immunocompromised status)

Does the patient meet any of the following criteria for Nirsevimab?

Other eligible medical condition

Has the patient previously received Nirsevimab or other RSV prophylaxis?

Provider Full Name

First NameLast Name

Provider Email Address

example@example.com

Provider Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Clinic or Practice Name and Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Additional Notes or Comments (optional)