PRE-APPT COVID FORM

Covid-19 Triage

Name*
First Last
Address
Street Address Address Line 2 City County EIRCODE Country
Date of Birth
MM slash DD slash YYYY
Email*
Phone*
GP Name*
Have you Received a Covid Vacine yet?*
Single Dose/Double Dose/Date Completed
Have you been sick in any way in the last 2 weeks? Headache, Nausea,Diarhea, Cough, Cold, Aches Pains*
Have you had/Do you have fever (over 37,5°C)?*
Do you have a sore throat or coughing at present?*
Have you lost your sense of smell or taste?*
Have you been in contact with somebody who has any of these symptoms?*
Have you travelled to an area at high risk for COVID-19, nationally or internationally?*
Do you work in a hospital/nursing home or healthcare facility?*
Have you been in contact with somebody that has COVID-19 OR TRACE CONTACTED BY HSE?*
Were you diagnosed with COVID-19?*
Have you been tested for Covid 19 or Covid 19 Anti-bodies?*
Do you live in a household with somebody who has been diagnosed with COVID-19 infection or has COVID-19 symptoms (fever, cough, loss of smell)?*
Contact Permission
I Agree to be contacted by phone & email in relation to this enquiry*
- YES
Patient Database Protection Permission Agreement
To facilitate your patient care, we need your permission to contact you and any other medical service providers agreed with you, during the course of your treatment, by email, SMS, phone and other electronic means. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes. All personal data which is emailed, is encrypted, password protected & GDPR compliant
Date
MM slash DD slash YYYY
Untitled

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PRE-APPT COVID FORM

Covid-19 Triage

Contact Permission

Patient Database Protection Permission Agreement