1 of 4 - Patient Details

How or where did you learn about this medical service?

Have you already booked an appointment time?*

YES
NO

What is the DATE of your medical consultation?

What is the TIME of your medical consultation ?

24 hour format

: HH

MM

Patient's Cellphone / Mobile Telephone Number?*

(a) Check that the telephone number is accurate. (b) On arrival at the Clinic ensure your mobile telephone has sufficient battery power and enough call credit to make a call to ask us to open the front door (there is NO intercom).

RE INPUT Telephone Number (Do Not Copy & Paste)*

It is really important that your telephone number is accurate

What is your 7 character EIRCODE?*

RE INPUT YOUR EIRCODE (Do Not Copy & Paste)*

Patient's First Name (or 1st Initial)?*

Patient's Last / Family Name / Surname (or Initial)?*

Sex*

Female
Male
Other

Patient's Date of Birth*

Email

Have you any concerns that you might have COVID-19?*

YES
NO

STOP - please go to www.COVIDA.ie & complete the Questionnaire ( find the link below )

go to https://covida.ie/ and wait for the clinic to telephone you. Please do not attend the clinic face to face and wait for your COVID-19 questionnaire to be reviewed. You will receive a telephone call from the clinic.

2 of 4 - Patient's GP (Doctor's Name & Medical Clinic)

Your GP Doctor - Name & Medical Centre?*

Who was the Doctor that you last attended - Name & Medical Centre?*

When did you last attend a Doctor or Medical Clinic?*

During last 1 month
During last 6 months
> 1 year ago
I never visited a Doctor or Medical Clinic in Ireland

Previously, have you attended Dr. Liam REGAN at this clinic (Nassau Street)?*

YES
NO

3 of 4 - Risk Factors

Have you an ALLERGY to any MEDICATION?*

YES
NO - I do NOT have an ALLERGY to any MEDICATION

List ALL medication that you are allergic to:

Are you taking regular MEDICATION?

YES
NO

List ALL medication that you take:

Are you pregnant?

YES
NO

Are you breast feeding?

YES
NO

4 of 4 - Reason for Medical Consultation?

Main Reason for Medical Consultation (Choose Only One)*

Please tick boxes that may describe your skin condition:

Please tick boxes that may describe your Ear problem:

Ear Infection
Ear Wax Removal
Swimmer's Ear

Please tick boxes that may describe your Eye skin condition:

Stye
Conjunctivitis

Please tick boxes that may describe your Women's Health:

Please tick multiple boxes that may describe your Men's Health:

What is your HIV Status?*

Before now, have you ever had an STI TEST?*

Yes
No

When was your last STI Test?*

When you tested before, did you have any infection?*

Yes
No

Tick if you previously had any of the following infections-*

Please tick boxes that may describe your Stress, Anxiety, Depression:

Depression
Panic Attacks
Stress

Please tick boxes that may describe your Cold, Flu, Respiratory conditions:blems:

Prescription - what is the medication, dosage & frequency?

What vaccine(s) do you need?*

Please provide a brief description of the Additional / Other medical issues not listed above:*

Who is responsible for arranging this consultation?*

PERSONAL - I am responsible for making & paying for this booking
INSURANCE - my insurance company is responsible for making & paying for this booking

Have you already PAID for your medical consultation?*

Yes
No

Are you attending in FACE-to-FACE or VIDEO / Telephone Consultation?*

Face-to-Face
Video / Telephone

You must pay in advance for a VIDEO / Telephone Consultation - Pay Now?*

YES Card Payment now
NO - please cancel this appointment

How do you want to pay?*

I will bring CASH to Clinic (we cannot accept cards at clinic)
CARD payment NOW

Choose Type of Medical Consultation*

(This will allow us to calculate the correct Payment Amount)

Total

0,00 €

Credit Card

Card Details

Cardholder Name

Email for Receipt

We will email a payment receipt to this address

Billing Address linked to Card

Address Line 1 Address Line 2 Address Line 3 EIRCODE Country

What is the name of your INSURANCE company that is paying for this consultation?*

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Patient Questionnaire