Covid-19 Referral

This form is strictly NOT for emergencies.

In case of emergencies, please contact the surgery directly

Check out the HSE website for useful information on how to manage Covid 19 queries and concerns

Covid Referral

I understand that this form is NOT to be used for Medically Urgent issues. It is only for use Monday to Friday 7am to 5pm *

I understand

Reason for making contact? *

First Name *

Last Name *

Date of Birth *

Patient PPS Number *

Phone Number
To enable HSE to contact you regarding the appointment *

Please tick all symptoms that apply to you *

Fever

New Cough

Shortness of Breath

Unexplained Muscle or Joint Pain

Diminished/Absent Sense of Smell/Taste

Household Contact of Known Positive Case

Workplace Contact of Known Positive Case

Formality for workplace/school/etc