Free Service – Application to be assessed by our GP for possible referral to the Free HSE COVID Testing Service COVID 25 Feb Application to be tested for COVID Book Now via https://www.nassau.ie/book(1) CONSENT - do you consent to the information you provide being shared with the HSE & DEASP?*YESNONote - fields with an asterisk * are obligatory In the last 3 WEEKS (21 days) did the patient apply for testing (Y/N)?*YESNOThe HSE already have your details on file. Please contact the HSE by telephoning 1850 24 1850As soon as the HSE answer your call choose from one of the following 6 options – *** 1. if you have received a text message with a positive test result. *** 2. if you have received a text message from the HSE to inform you that you are a close contact of someone that has tested positive. *** 3. if you are awaiting your test or have been offered a test appointment and are/ were unable to attend. *** 4. to enquire about test results. *** 5. if you received a close contact alert via the COVID Tracker App. *** 6. for general information and advice on Covid-19.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?NoYesFor 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 TESTNEW - If you have arrived recently from Britain, South Africa or Brazil you can apply to be tested.Did you ever apply to tested before (Privately or at Work or by the HSE) ?*YESNOFor certainty, we ask again - BEFORE THIS APPLICATION, DID YOU EVER PREVIOUSLY APPLY TO BE TESTED (Privately or at Work or by the HSE) ?*YESNOOn 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?*YESNODid you attend for testing?*YESNOWhat was the result?*NegativePositiveAwaiting my resultWhy 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 Tick all relevant boxesWhat date did you arrive in Ireland?* Date Format: DD dash MM dash YYYY Do you have an Irish PPS Number?*YesNoWhat 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 DetailsPatient's Family Name / Surname?*Patient's First Name?*Patient's Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DAY ****** MONTH **** YEARValidator 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)*NOYESStarts 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 NumberEmail* SEX*FemaleMaleOtherWhat is the name of your Doctor or last clinic that you visited (OBLIGATORY)?*3 of 3 - COVID-19 Risk FactorsAre you IMMUNOSUPPRESSED?*YESNOPlease provide details of your decreased immunity?*Please describe your COVID like symptoms (OBLIGATORY)?*Do you have a NEW cough?*YESNODo you have NEW shortness of breath?*YESNOHave you lost your sense of SMELL?*YESNOHave you lost your sense of TASTE?*YESNODo you have muscle or joint pain?*YESNODo you have a fever?*YESNO