Symptomatic COVID-19 Form

Updated Guidelines have been Issued by the Department of Health and HSE in relation to Covid 19 testing.

If you experience respiratory distress in the form of either a cough or shortness of breath, Fever/Chills OR a sudden loss of taste, smell or a distortion of either please submit the form below. 
If you are a close contact of a person with covid 19, YOU NO LONGER WILL BE AUTOMATICALLY TESTED FOR COVID 19. the HSE ask that you follow their advice viewable here.  Do not complete the below form unless you have symptoms of covid 19.

IF YOU ARE COMPLETING THIS FORM FOR ANOTHER MEMBER OR MEMBERS OF YOUR FAMILY/BUBBLE PLEASE LET RECEPTION KNOW BY EMAIL SO THAT WE CAN GROUP YOU TOGETHER.

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

Mobile phone number preferred so that we can text you
Please format your date like this: 15/06/1970
(Needed if you wish the HSE to pay for your consultation)


If you have one








Tick as many as apply to you.


This is recommended if you have any of the breathing symptoms outlined above.
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.










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WHAT HAPPENS 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