GP Referral COVID (Jan 2021) Application to be tested for COVID Book Now via https://www.nassau.ie/bookIn the last 2 WEEKS (14 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-19.1 of 4 - REQUEST FOR FREE COVID TESTINGNEW - Visitors from Britain and Northern Ireland can apply to be tested if they provide their NHS Number, or UK Driving Licence Number or Passport Number. (1) CONSENT - do you consent to the information you provide being shared with the HSE & DEASP?*YESNOAre you VISITING from Britain or Northern Ireland ?YESNOWhat Identification Number can you provide* NHS Number UK Driving Licence Passport Number Irish PPS Number Tick one or more Enter ID Number(s)PPSN - Personal Public Service Number*7 numerical characters followed by 1 or 2 alphabetical characters What is your 7 character EIRCODE?*VERY IMPORTANT - You can find your EIRCODE (which is 7 characters long) using the following link https://finder.eircode.ie/#/RE INPUT your EIRCODE (Do Not Copy & Paste)*VERY IMPORTANT THAT THIS IS ACCURATEApt, Flat or House Number and Street NameHave you previously made an application to be tested?*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?*2 of 4 - Patient DetailsPatient's Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DAY ****** MONTH **** YEARPatient's Family Name / Surname?*Patient's First 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)*International Mobile - Country Code and NumberEmail* SEX*FemaleMale__Other_3 of 4 - COVID-19 Risk FactorsWhy do you want to be tested?* Close Contact of a person that tested positive for COVID I have COVID symptoms Recently arrived in Ireland (for a visit or returning home from a holiday) NOT SICK - re-assurance / peace of mind I am a Health Care Worker Did the close contact (that tested positive) recently arrive from Britain or Northern Ireland or South Africa?NOYESWhat is the name and contact number of the close contact?What date did you arrive in Ireland? Date Format: MM slash DD slash YYYY In respect of the person that was confirmed as having COVID-19 is any of the following true:* I was less than 2 metres from them I spend more than 15 minutes with them On what date (approximately) did that person test positive?* Date Format: DD dash MM dash YYYY What is your relationship to the person who tested positive?* Partner Live in same house Work School or College Friend Restaurant Social Occasion What is the name of the person who tested positive?*Do you have a thermometer to measure your temperature?YESNOWhat is your temperature as measured by your thermometer?Do you have a cough?YESNODo you have shortness of breath?YESNOHave you lost your sense of SMELL?YESNOHave you lost your sense of TASTE?YESNOName the Health Care facility, location and your responsibilities?*Are you IMMUNOSUPPRESSED?YESNOPlease provide details of your decreased immunity?TRAVEL - In the past 30 days have you been outside of the island of Ireland?*YESNOPlease click each one of the following places that you visited (or transit through): China Hong Kong Iran Japan South Korea Singapore Europe Another country not listed above What other country / continent did you visit?Please click each one of the following European places that you visited (or transit through): Italy France Germany Spain Britain Other European countries not listed above What other European countries did you visit?TRANSPORT - what methods will you use to travel to the COVID Test Centre?* Car or Taxi Bicycle / Scooter Walk You are not permitted to use a bus or train as there is a risk that you may infect other people. 4 of 4 - 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.If the Doctor directs you to self-isolate 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/