Please read this carefully. Due to the increased volume of queries about Coronavirus testing we are now asking symptomatic patients to fill out the following questionnaire to help us assess you more efficiently.

  • This form is only for registered patients of our practice.
  • You must call us on 018461335 or 018038881 to arrange an appointment to speak to one of our team BEFORE you fill this form out.

We understand our patients are concerned for themselves and their loved ones and we can assure you we are doing everything we can to operate as normally as possible in these busy times, while at the same time minimising the risk of exposure to our patients or indeed our practice.

Please fill out the below form to help us triage your symptoms to see if you need testing for Covid-19*

    Please outline your symptoms below:

    Duration of Symptoms*:
    When did you start displaying symptoms?

    Severity of Symptoms*:
    How severe are your symptoms?

    Recent Travel/Contact with confirmed Coronavirus case*
    Have you travelled to an area affected by the Coronavirus or been in close contact with a confirmed case of Coronavirus - this is not required for Covid-19 testing, however, it is useful information.

    Are you currently self-isolating*?
    Anybody with respiratory symptoms of any kind is now advised to self-isolate.

    Brief outline of your symptoms/concerns*:
    Please give a brief outline of your symptoms, when they started and your concern re-testing. If you have any other symptoms not covered in the checklist above, please let us know here also.

    Pre-existing medical conditions
    Please outline any significant pre-existing medical conditions that may put you in an at-risk category

    Please Note:
    All forms received by lunchtime will be processed on the day they are received and will receive a callback, those received after 13h00 may not be called back until the day after they are received.

    We will only use the information you provide us in this form to deal specifically with you and your COVID symptoms and we will not use it for any other purpose.

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    Next Steps:

    On receipt of the form, one of the practice doctors will contact you to confirm receipt at the time you have arranged and will clarify any issues via phone consultation.

    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).

    • If your symptoms worsen whilst you are awaiting testing, please contact us so we can further evaluate your status.
    • While you are waiting for us to contact you, you must self-isolate at home to help slow the spread of the virus.
    • Please do not come into the practice as you risk passing on the infection to other patients and our staff.

    Further information:

    • Useful information on self-isolation can be found on the HSE’s information page here.
    • Useful information on the virus can be found on the HSE Covid-19 page here.
    • For travel advice, please visit the Department of Foreign Affairs Travel Advisory page here.

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

    *Please note, by completing this form you consent for your data to be sent by automated email to your GP practice’s nominated email account. No personal data is stored on this website or website provider to the website author’s knowledge. The website author takes no responsibility for incorrect details provided by your GP practice.