New Guidelines have been Issued by the Department of Health and HSE in relation to Covid 19 testing. Only at risk patients and patients with a fever (over 38 Degrees) and a cough/shortness of breath/respiratory distress will now be tested.

If you are currently awaiting your Covid 19 test, having been referred by your GP, you will not be tested unless your GP refers you again as an at-risk patient (as determined by your GP) or you have the above symptoms as per the World Health Organisation case definition.

Anybody who does not meet this World Health Organisation Case Definition but is still displaying symptoms is advised to stay at home and self isolate for 14 days from the start of their symptoms, the last 5 of which they must have no fever.

PATIENT DETAILS

Name (*):

Email (*):

Full Address:
Please include your eircode

Date of Birth (*):
Please format your date like this: 15/06/1970

Contact Number (*):
Mobile phone number preferred so that we can text you

PPS:

Medical Card Number:

Do you work in Healthcare? (*):

Are you over 60? (*):

Your Symptoms (*):
Tick as many as apply to you.

Additional Symptoms:

Are you self isolating? (*):
This is recommended if you have any of the breathing symptoms outlined above.

Underlying Health Conditions:
If you have any underlying health conditions or are immunosuppressed, have chronic lung disease, chronic heart disease, cerebrovascular disease, chronic renal disease, chronic liver disease or are a smoker please tell us here.

Have you been in contact with a person confirmed with the Coronavirus in the last 14 days?:

Do you live with someone who is immunosuppressed, has chronic lung disease, chronic heart disease, cerebrovascular disease, chronic renal disease, chronic liver disease or is a smoker?:

Do you work in or are you completing this form on behalf of a person in a long term care facility?:

Do you work in or are you completing this form on behalf of a prison inmate?:

Are you pregnant?:


Important notice : We will process your data under Vital Interest . Please refer to our Privacy Statement for full details.

WHAT NEXT?

We will contact you and review your symptoms with you either by phone or video consultation as needed.

If necessary, we will submit a request referral to the National Ambulance Service to have you tested for Covid-19. The National Ambulance Service will contact you directly to arrange this and give further information.

If you need to contact us in the meantime, please phone or email us and we will respond as quickly as possible. Do not enter the practice, for the sake of your community and the staff of the practice.

Until your test shows that you are not carrying the Covid-19 virus, it is vital that you self-isolate at home - general information and advice on how to self isolate is available on our website and on the HSE website: https://www2.hse.ie/conditions/coronavirus/coronavirus.html