Symptomatic COVID-19 Testing Form
Mercer's Medical Centre, Stephen Street Lower, Dublin 2
Opening hours: Monday to Friday, 9am - 5pm.
Are you/the patient registered with Mercer's Medical Centre? *
Name and surname of patient who may need testing *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Contact telephone number *
Your answer
Address including Eircode if known *
Your answer
Email address
Your answer
PPS number *
Your answer
Medical card number
Your answer
Are you/the patient in any of the following categories? *
Required
If yes to any of the above, please detail below:
Your answer
Symptoms *
Required
Are you currently self-isolating?
Brief outline of your symptoms/concerns, timeline of same, and any other information you need us to know. *
Your answer
Pre-existing medical conditions *
Your answer
Consent to process your data for purposes of COVID-19 assessment *
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