Dalkey Podiatry Clinic Triage Form for Covid-19.

In line with HSE guidelines to prevent the spread of COVID-19, we have introduced a new triage procedure.

When you receive your appointment date and time from the clinic, please fill out this form which is required by the HSE, and submit it to us at the clinic.

Please do not fill it in before you have your appointment details.

See our safety measures in place at Dalkey Podiatry Clinic

    Your name (required)
    Your email (required)
    Your date of birth
    Phone Number (required)
    When is your appointment booked for?*
    What time is your appointment?*
    Have you been to one of the COVID-19 affected countries in the last 14 days?
    YesNo
    Are you currently experiencing COVID-19 symptoms (new continuous cough, shortness of breath, fever in excess of 37.5C or a los of smell/taste ?
    YesNo
    Please specify any cities/countries that you have travelled to in the last 14 days (leave blank if you have not travelled)
    Please specify details of any symptoms (leave blank if you have no symptoms)

    Have you been in close contact with a suspected OR confirmed case of COVID-19?
    YesNo
    Have you attended any other medical facility in the last 14 days to receive any medical attention?
    YesNo

     

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