Pre Treatment Screening Check

Thanks. We have received your appointment form. Please fill out the form below prior to your visit. 

I understand that this information is required for the purpose of public health and will be kept on file
for a 2 month period from the date of signing. I confirm that the above information is true and
accurate from the date of signing. I understand that my personal information including my name and
contact details may be shared with the Health Service Executive (HSE) for the sole purpose of
contact tracing in line with public health guidelines only if requested.