Nassau Clinic – Free HSE PCR Test if you have symptoms and are aged (a) 40 years & older or (b) <4 years COVID 2021 Application to be tested for COVID First try to book directly with the HSE website. If there is no availability and you have tried again without success then we in the Nassau Clinic will try and book an appointment for you - to enable us to do so, you must complete the following form. You must have SYMPTOMS and either be (a) Aged 40 & older or (b) Aged < 4 Years. *** NEW *** HSE PCR Testing is NOT available for those aged 4 to 39.(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 obligatoryEntitlement 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 TESTIn the last 2 weeks did you apply, via THIS this website COVIDA.ie for a free HSE PCR test* 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, IN THE LAST 2 WEEKS DID YOU APPLY, VIA THIS WEBSITE COVIDA.ie TO BE TESTED 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* Aged 40 or older and have COVID symptoms Aged 1 to 3 and have COVID symptoms I am a Health Care Worker At what health care facility are you employed* 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 2 of 3 - Patient DetailsPatient's Family Name / Surname?* Patient's First Name?* Patient's Date of Birth*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DAY ****** 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 Your full address* 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 FactorsIn the past 24 hours did you do a rapid Antigen Test wand get a result of POSITIVE / DETECTED* YES NO 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