COVID 19 TEST REQUEST

Please answer all questions

Then click on the "submit" button below

First Name Surname and Date of Birth

Address - Include Eircode for National Ambulance Service

Mobile Phone Number

This service is ONLY available for patients of Millmount Medical Centre. Please contact your own GP if you are not registered as a patient. Are you a patient of this practice?

Yes

Have you travelled to an area affected by the Coronavirus or been in close contact with a confirmed case of Coronavirus?

Yes

Are you currently self isolating? * Anybody with respiratory symptoms of any kind is now advised to self-isolate.

Yes

How severe are your symptoms?

Mild

Moderate

Severe

Very severe (If so please call an ambulance through emergency services)

What are your symptoms? Tick all that apply.

Fevers/Chills (fever usually above 38 degrees)

Cough (can be dry or productive/chesty)

Difficulty Breathing/Shortness of Breath

Aches & Pains

Fatigue

Sore throat

Runny nose

Diarrhoea

Vomiting

No symptoms (if you have no symptoms, you are unlikely to meet the criteria for testing)

Thanks for submitting!

Prescription Request
Please list all medications
Then click on the "submit" button below

First Name Surname and Date of Birth

Medical Card Number (if non please write None)

Mobile Phone Number

Medication name, dose

Have you travelled to an area affected by the Coronavirus or been in close contact with a confirmed case of Coronavirus?

Yes

Are you currently self isolating? * Anybody with respiratory symptoms of any kind is now advised to self-isolate.

Yes

How severe are your symptoms?

Mild

Moderate

Severe

Very severe (If so please call an ambulance through emergency services)

What are your symptoms? Tick all that apply.

Fevers/Chills (fever usually above 38 degrees)

Cough (can be dry or productive/chesty)

Difficulty Breathing/Shortness of Breath

Aches & Pains

Fatigue

Sore throat

Runny nose

Diarrhoea

Vomiting

No symptoms (if you have no symptoms, you are unlikely to meet the criteria for testing)

Thanks for submitting!

Covid 19 Test Request - for patients with symptoms

If you are requesting a Private PCR test please ring the surgery

Please answer all questions -then click on the "SUBMIT" button.

If you need medical advice from a Doctor please DO NOT SUBMIT this form

-Either ring the surgery (0449390033) or Middoc Out of Hours (1850 302 702)

-or for emergencies please attend the hospital A/E unit or ring 999 / 112

We submit requests on behalf of our patients each week day during surgery hours - it is not monitored out of hours or at weekends - requests will be submitted the following morning (or Monday morning for weekend requests.)

For information on management of symptoms of COVID 19, refer to our

home page and updated advice on the HSE website.

If you need medical advice please DO NOT ATTEND THE SURGERY but instead please ring the surgery.

Due to current demands on HSE service, there are delays on patients receiving a test appointment from the HSE. There may be further delays after the test for the result to come back.

The practice has no say in these decisions. Please be patient at this time.

Please self-isolate (click here for advice) until you have received the result of your test.

The patient will receive a text from the testing system to advise them of their time/location for testing.

After testing the following will apply:

If negative the patient will receive a text directly from the testing system advising that text was negative. The GP may not receive this result.
If positive the patient will receive a call from public health for contact tracing

First Name Surname and Date of Birth

Address - Include Eircode for National Ambulance Service

Mobile Phone Number

Valid Medical Card Number and PPS Number (Test requests cannot be sent without PPS Number.)

This service is ONLY available for patients of Millmount Medical Centre who are NOT in need of medical advice at this time. Please contact your own GP if you are not registered as a patient. Please ring Millmount Medical Centre if you need medical advice or for emergencies attend A/E or ring 112 or 999. Please confirm that you understand this regarding your PCR test request.

Yes

Have you travelled to an area affected by the Coronavirus or been in close contact with a confirmed case of Coronavirus?

Yes

Are you currently self isolating? * Anybody with respiratory symptoms of any kind is now advised to self-isolate.

Yes

How severe are your symptoms?

Mild

Moderate

Severe ( Please do NOT submit this form and instead ring the surgery if medical advice is required)

Very severe (If so please call an ambulance through emergency services)

What are your symptoms? Tick all that apply.

Contact of Positive case - no symptoms

Pre Hospital Procedure testing

Travel from UK / Brazil/South Africa or designated Red Zone Country

Loss of sense of smell or taste

Fevers/Chills (fever usually above 38 degrees)

Sore throat / Ear Infection / Chest infection / Sinusitis

Cough (can be dry or productive/chesty)

Difficulty Breathing/Shortness of Breath

Patient with acute respiratory infection (sudden onset of at least one of the following: cough, fever, shortness of breath) AND with no other cause that fully explains the clinical presentation

Any acute respiratory illness AND having been in close contact with a confirmed or probable2 COVID-19 case in the last 14 days prior to onset of symptoms

Nausea, vomiting diarrhoea

Past medical history. Please tick all that apply. (Ref updated algorithm for Covid testing)

NONE

FRONT LINE HEALTH CARE STAFF OR SIMILAR

CONTACT of person with positive test for Covid 19 / Staff and residents of nursing homes and other residential care settings and those in direct provision, homeless, Roma and travelling community settings where symptom management is difficult.

chronic lung disease, chronic renal disease, chronic liver disease

Asthma

Ischaemic heart disease / Heart attack, hypertension / high blood pressure, cerebrovascular disease / Stroke

Current pregnancy

On immune suppression medication

On chemotherapy for cancer / Cancer

On treatment for autoimmune diseases, such as rheumatoid arthritis, lupus, multiple sclerosis (MS) and inflammatory bowel diseases, HIV, having an organ transplant or a bone-marrow transplant

Aged over 70 years old

Diabetes mellitis

High Blood Pressure, Diabetes, Obesity, active malignancy in last 5 years

rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell).

Prison staff

Thank you. Your request has been sumitted. Requests are forwarded to the HSE each week day for our patients. The national ambulance service will text you in the coming days with an appointment.

Millmount Medical Centre

General Practice Mullingar

Phone : 044 9390033

Covid 19 Test Request

Please answer all questions

Then click on the "submit" button below

Prescription Request
Please list all medications
Then click on the "submit" button below

Covid 19 Test Request - for patients with symptoms

If you are requesting a Private PCR test please ring the surgery

Please answer all questions -then click on the "SUBMIT" button.

If you need medical advice from a Doctor please DO NOT SUBMIT this form

-Either ring the surgery (0449390033) or Middoc Out of Hours (1850 302 702)

-or for emergencies please attend the hospital A/E unit or ring 999 / 112

Millmount

Medical

Centre

Tel 044 9390033

Eircode N91 HW21

Covid 19 Test Request

Please answer all questions

Then click on the "submit" button below

Prescription Request Please list all medications Then click on the "submit" button below

Covid 19 Test Request - for patients with symptoms

​

If you are requesting a Private PCR test please ring the surgery

Please answer all questions -then click on the "SUBMIT" button.

If you need medical advice from a Doctor please DO NOT SUBMIT this form

-Either ring the surgery (0449390033) or Middoc Out of Hours (1850 302 702)

-or for emergencies please attend the hospital A/E unit or ring 999 / 112

​

​

​

Prescription Request
Please list all medications
Then click on the "submit" button below