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 obligatoryIn 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. In Ireland, were you ever called for an appointment and then you either cancelled or did not attend ?* YES NO Note 2. If your response is inaccurate or incomplete, THIS application will NOT be processed. THE HSE (Telephone 1850 24 1850) ALREADY HAVE YOUR APPLICATION CONTACT DETAILS & CAN ADVISE YOU REGARDING ANY ADDITIONAL COVID TESTINGMore 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. The E-Cert will be issued by the Doctor once your test results are back. NOTE - if you do not attend or cancel your test appointment, an E-Cert for a DEASP COVID Payment will NOT be issued.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 TESTNEW - 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?* 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 boxesWhat date did you arrive in Ireland?* 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).HiddenValidator 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*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DAY ****** MONTH **** YEARHiddenValidator 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).HiddenValidator 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.HiddenValidator 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 FactorsAre 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