Free Service – Application to be assessed by our GP for possible referral to the Free HSE COVID Testing Service

COVID April 2021

Application to be tested for COVID

(1) CONSENT - do you consent to the information you provide being shared with the HSE & DEASP?*
- YES
- NO
Note 1. Fields with an asterisk * are obligatory
In Ireland, in the last 2 weeks, did you apply to be tested for COVID?*
- YES
- NO
Note 2. If your response is inaccurate or incomplete, THIS application will NOT be processed.
THE HSE (Telephone 1850 24 1850) CAN ADVISE YOU REGARDING ANY ADDITIONAL COVID TESTING
More details on FAQ 13 (Sub Section 13) - use the following link https://www.nassau.ie/faq/
Entitlement to COVID-19 Payments of €350 per week.
If the Doctor directs you to self-isolate, you may be entitled to a COVID-19 payment of €700 (€350 per week for 2 weeks) from the Department of Employment Affairs and Social Protection (DEASP) on condition that the Doctor issues a “Medical E-Certificate of Incapacity for Work” to the DEASP.
Do you want us to send a “Medical E-Certificate of Incapacity for Work” to the DEASP?
- No
- Yes
For additional information on "Medical E-Certificate of Incapacity for Work" read FAQ 13 on our website https://www.nassau.ie/faq/
WARNING - you must complete Section 1 and 2 and 3 before pressing the button "Send to Doctor for review". Once submitted then wait until message from Nassau Clinic appears saying "Thank You For our Completed COVID Application Form"
1 of 3 - I HAVE COVID SYMPTOMS & REQUEST A FREE COVID TEST
NEW - If you have arrived recently from Britain, South Africa, Brazil or other Category 2 countries you can apply to be tested.
Did you ever apply to tested before (Privately or at Work or by the HSE) ?*
- YES
- NO
Note 2. If your response is inaccurate or incomplete, THIS application will NOT be processed.
For certainty, we ask again - BEFORE THIS APPLICATION, DID YOU EVER PREVIOUSLY APPLY TO BE TESTED (Privately or at Work or by the HSE) ?*
- YES
- NO
Note 3. If your response is inaccurate or incomplete, THIS application will NOT be processed.
On what date did you submit your application to be tested?*
Date Format: DD dash MM dash YYYY
Were you offered a test date and time?*
- YES
- NO
Did you attend for testing?*
- YES
- NO
What was the result?*
- Negative
- Positive
- Awaiting my result
Why did you not attend?*
Why do you want to be tested?*
- I have COVID symptoms
- I am a Health Care Worker
- Recently arrived from Britain
- Recently arrived from Brazil
- Recently arrived from South Africa
- Recently arrived from another high risk (Category 2) country
Tick all relevant boxes
What date did you arrive in Ireland?*
Date Format: DD dash MM dash YYYY
Do you have an Irish PPS Number?*
- Yes
- No
What is the patient's PPSN?*
Please enter a valid PPSN (8 or 9 characters long).
Validator 1
- Valid PPSN
What Identification Number can you provide*
- NHS Number
- UK Driving Licence
- Passport Number
Tick one or more
Enter ID Number(s)
2 of 3 - Patient Details
Patient's Family Name / Surname?*
Patient's First Name?*
Patient's Date of Birth*
DAY ****** MONTH **** YEAR
Validator 4
- Date of Birth
What is the patient's PPSN?*
Please enter a valid PPSN (8 or 9 characters long).
What is the patient's Eircode?*
Please enter a valid Eircode (7 characters long).
Validator 2
- Valid PPSN
- Valid Eircode
House Number (Apt / Flat) and Street Name*
Is mobile telephone number from Ireland? (commences with 08)*
- NO
- YES
Starts with*
- (083)
- (085)
- (086)
- (087)
- (089)
Last 7 numbers (XXX-XXXX)*
Re INPUT Your Mobile Telephone Number (08X XXX-XXXX)*
Number must match one entered above.
Validator 3
- Valid Mobile Number
International Mobile - Country Code and Number*
Email*
SEX*
- Female
- Male
- Other
What is the name of your Doctor or last clinic that you visited (OBLIGATORY)?*
3 of 3 - COVID-19 Risk Factors
Are you IMMUNOSUPPRESSED?*
- YES
- NO
Please provide details of your decreased immunity?*
Please describe your COVID like symptoms (OBLIGATORY)?*
Do you have a NEW cough?*
- YES
- NO
Do you have NEW shortness of breath?*
- YES
- NO
Have you lost your sense of SMELL?*
- YES
- NO
Have you lost your sense of TASTE?*
- YES
- NO
Do you have muscle or joint pain?*
- YES
- NO
Do you have a fever?*
- YES
- NO

COVID April 2021

THE HSE (Telephone 1850 24 1850) CAN ADVISE YOU REGARDING ANY ADDITIONAL COVID TESTING

Entitlement to COVID-19 Payments of €350 per week.

WARNING - you must complete Section 1 and 2 and 3 before pressing the button "Send to Doctor for review". Once submitted then wait until message from Nassau Clinic appears saying "Thank You For our Completed COVID Application Form"

1 of 3 - I HAVE COVID SYMPTOMS & REQUEST A FREE COVID TEST

2 of 3 - Patient Details

3 of 3 - COVID-19 Risk Factors