Brooklane Medical

Brooklane Medical Health Clinic Bandon Cork

Opening Hours

Monday to Friday: 09.15 - 12.30 & 14.30 - 17.00

Call Us

+353 23 887 8181

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COVID 19 Testing Form

Symptomatic COVID-19
Testing Form for BrookLane Medical

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*

COVID 19 Testing Form

When did you start displaying symptoms
Anybody with respiratory symptoms of any kind is now advised to self-isolate.
History of ischaemic heart disease, high blood pressure, history of Stroke/TIA, Type II diabetes, obesity, active malignancy in last 5 years, chronic lung disease, chronic renal disease, chronic liver disease.
History of ischaemic heart disease, high blood pressure, history of Stroke/TIA, Type II diabetes, obesity, active malignancy in last 5 years, chronic lung disease, chronic renal disease, chronic liver disease.
How severe are your symptoms?
Have you been in close contact with a confirmed coronavirus case?
Are you a healthcare worker with patient-facing contact?
Are you a healthcare worker with patient-facing contact?
Are you a healthcare worker with patient-facing contact?
Please give a brief outline of your symptoms, when they started and your concern re testing. If you have any other symptoms not covered in the checklist above, please let us know here also.

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We will contact you as soon as possible.