Symptomatic COVID-19 Testing Form for Bedford Medical Centre, Navan

Due to the increased volume of phone and email queries about Coronavirus testing in light of broadening of testing criteria announced by the HSE – we are now asking symptomatic patients to fill out the following questionnaire to help us assess you more efficiently.

We understand our patients are concerned for themselves and their loved ones and we can assure you we are doing everything we can to operate as normally as possible in these extraordinary times, while at the same time minimising the risk of exposure to our patients or indeed our practice.

Please fill out the below form to help us triage your symptoms to see if you need testing for Covid-19*

Name

Mobile Number

PPSN - If GMS or Doctor visit card patient enter 0

Date of Birth

Address 1

Address 2

Town/City

County

Eircode

Country

Symptoms

Fever

When did you start dsplaying symptoms?

How severe are your symtoms?

Are you currently Self Isolating?

Have you been in close contact with a confirmed coronavirus case?

Are you an exisiting patient of this practice or are you a new patient?

Are you in an at risk Group? (History of ischaemic heart disease, high blood pressure, history of Stroke/TIA, Type II diabetes, obesity, active maignancy in last 5 years, chromic lung disease, chronic renal disease, chronic liver disease.

Are you a houshold contact of an at-risk group?

Do you work in the Prison Service?

Are you currently pregnant?

Are you a staff or resident in a long-term care facility or nursing home?

Brief Outline of your Symptoms/Concerns

By submitting this form, I consent to my data being stored, analysed and transferred to this GP practice for screening. I agree to the website privacy policy and I also agree to take responsibility to follow up with up GP practice directly if I have not heard back from them within 48 hours. You’ll receive an email with your details shortly.