Form for close contacts of people with confirmed COVID 19 and no symptoms

This form allows you to submit information if you have been a close contact of someone with COVID 19 AND HAVE NO SYMPTOMS. You will normally have received a text message from public health or from the person themselves advising you are a close contact. Click here for further details about close and casual contacts

It is for patients of the Palms GP Surgery only. Unfortunately we do not have capacity to deal with other queries from people outside our surgery at present.

If you have symptoms do not use this form. Contact the surgery by phoning on 053 9421336 or out of hours contact Caredoc on 0818 300 365

This is not for urgent clinical queries.

While awaiting advice you must follow advice of HSE regarding self isolation or restricted movements here

Full Name *

Phone

Email *

PPS Number (or GMS Number if you have a medical card or doctor visit card) *

Date of Birth

Are you a close contact of someone with COVID 19 infection? *

This form is only for contacts of those with confirmed COVID 19 infections. If you are not a contact of someone with confirmed COVID-19 infection please contact the surgery by phone on 053 9421336 to get advice on your concern

Do you have any symptoms of respiratory infection (any of fever, cough, shortness of breath, change in taste or smell, sore throat or runny nose) *

This form is only for people with NO symptoms who are contacts of a confirmed COVID 19 case. If you have any symptoms please contact the surgery on 053 9421336 for advice or email info@thepalmssurgery.com

Date of last contact with person with COVID-19 infection *

Please enter date of last contact you had with the person with COVID 19 infection. If they are living with you please enter today's date

Do you require a social welfare cert?

Do you require a cert for work?

Have you had a COVID 19 booster dose (i.e. third dose) more than 7 days ago?

By submitting this form I consent to my data being stored, analysed and transferred to the GP practice for screening. I agree to the privacy policy. I will contact the GP practice directly if I have not heard back within 48 hours. If I develop symptoms I will contact my GP or Caredoc out of hours. If there are other people who require testing I will submit a separate form for them *

I agree

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