GeoMed Diagnostics Laboratory Request Form
GeoMed Diagnostics
Personal Information
First Name
*
Last Name
*
Gender
*
Please, select
Female
Male
Date of Birth
*
Use this format: day/month/year. Example: 27/04/2024
Email Address
*
Phone
*
Address
*
Eircode
County of Residence
*
Please, select
Carlow
Cavan
Clare
Cork
Donegal
Dublin
Galway
Kerry
Kildare
Kilkenny
Laois
Leitrim
Limerick
Longford
Louth
Mayo
Meath
Monaghan
Offaly
Roscommon
Sligo
Tipperary
Waterford
Westmeath
Wexford
Wicklow
Appointment Details
Please, select a date:
Please, select a time:
Final Details
You hereby agree that GEOMED may provide your name if you are tested positive solely for the purpose of tracing potential contacts, preventing further infection and providing necessary care to yourself
You hereby agree to undergo the test, agree that the test results will remain confidential and only accessible to You, GEOMED and HSE Public Health (for positive results only)
Continue to Payment
Amount due:
€109
