Covid 19 Symptomatic Testing Form

Following the announcement by the HSE of the change in testing criteria for Coronavirus/Covid19, please visit https://www2.hse.ie/conditions/coronavirus/testing.html. If you meet the criteria please fill out the following questionnaire to help us assess you more efficiently.

Name (* Mandatory Field)

Date of Birth (*)

Address (*)

Eircode (this is necessary if the National Ambulance Service needs to do a home visit) (*)

Email (*)

Mobile (*)

Alternative Number

PPS/GMS/DVC Number (*)

Occupation (*)

Please confirm which symptoms you are suffering from:(*)

Fever/Chills (Temperature above 38 degrees)Runny NoseBlocked NoseFacial Pain or PressureSore ThroatHoarsenessEaracheCoughLoss of Taste or SmellChest Pain or TightnessDifficulty BreathingVomitingDiarrhoeaRash

Duration of Symptoms: (*)

Severity of Symptoms: (*)

Have you been self isolating: (*)

Antigen Test Result: (*)

Do you have any underlying medical conditions (*)

Are you Pregnant? (*)

Have you transport available to attend a testing centre, if necessary: (*)

Any Further Information (to assist in managing your case)

By submitting this form you are consenting to us contacting you by text to inform you as to the next steps.

Next Steps

  • On receipt of the form, one of the practice doctors or nurses will contact you to confirm receipt and clarify any issues via phone consultation, if needed
  • If you meet the current criteria for Covid-19 testing as outlined by Health Protection Surveillance Centre Guidelines, we will submit an e-referral to request Covid-19 testing to the National Ambulance Service (NAS).
  • We will send you a text message to confirm that the referral has been sent.
  • NAS will review your referral and they will contact you directly, if deemed appropriate, to arrange this and give further information. This may take a number of days depending on demand and we have no way of speeding this up, please be patient.
  • If your symptoms worsen whilst you are awaiting testing, please contact us.
  • While you are waiting for us to contact you, please, please, please self-isolate at home to help slow the spread of the virus.
  • Please do not come in to the practice as you risk passing on infection to other patients and our staff.

Please be sensible and follow all official advice coming from HSE and public health. Please avoid putting any vulnerable groups in the population at increase risk unnecessarily.

Monday ā€“ Friday 8.00am to 5.30pm
Saturdays, Sundays & Bank Holidays ā€“ Closed

Monday ā€“ Friday 9.00am to 5.00pm
Saturdays, Sundays & Bank Holidays – Closed