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 (*)

Occupation (*)
---Healthcare WorkerTeacherNeither of the Above

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: (*)
---Today1 - 3 Days3 - 5 Days5 - 7 DaysLonger than 7 Days

Severity of Symptoms: (*)
---MildModerateSevere (Please call the practice or an ambulance if severe)

Have you been self isolating: (*)
---YesNo

Antigen Test Result: (*)
---PositiveNegative

Do you have any underlying medical conditions (*)

Are you Pregnant? (*)
---YesNo

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

Any Further Information (to assist in managing your case)

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