Tecovirimat (TPOXX) Provider Ordering Form
Public Health – Dayton & Montgomery County will process your TPOXX order once this electronic ordering form has been received and reviewed. If there are questions, Public Health may need to speak with you prior to filling your request.
Providers are encouraged to inform patients with mpox about STOMP and to recommend they consider seeking enrollment in STOMP, which has randomized and open label treatment arms. Patients do not have to have severe disease or be at high risk of severe illness to enroll in the study, and remote enrollment is available.
Tecovirimat, also known as TPOXX, is an antiviral drug that is FDA approved for the treatment of smallpox. TPOXX is available for the treatment of MPX Monkeypox under a CDC Expanded Access Investigational New Drug (EA-IND) protocol (IND Protocol Link).
Because TPOXX is an investigational drug, patients must meet criteria (specified below) and have a medical provider who obtains consent, completes CDC forms, and monitors the patient during and after treatment.
Public Health – Dayton & Montgomery County will process your TPOXX order once this electronic ordering form has been received and reviewed. If there are questions, Public Health may need to speak with you prior to filling your request.
Please note there are additional CDC forms that must be completed before (patient consent) and after (patient intake form; FDA 1572 form) initiation of treatment. The MedWatch form must be completed if there are adverse reactions. Additionally it is recommended that providers complete the clinical outcome form after treatment.
If you have questions prior to submission please contact us at (937) 225-4508
