Covid 19

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 (*)

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

Fever/Chills (Temperature above 38 degrees)CoughBreathing Difficulties/Shortness of BreathSore ThroatRunny NoseDiarrhoeaVomitingAches and PainsFatigueNone of the Above (unlikely to be accepted for testing)

Duration of Symptoms: (*)

Severity of Symptoms: (*)

Have you been self isolating: (*)

Do you have any underlying medical conditions (*)

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.

Monday – Friday 8.00am to 5.30pm
Saturday 9.00am – 12.00pm
Sundays & Bank Holidays – Closed

Monday – Friday 9.00am to 5.00pm
Saturday 9.00am -12.00pm – Emergency Walk in Clinic Only (No Appointments)
Sundays & Bank Holidays – Closed