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  • WALK-UP COVID TESTING

    WALK-UP COVID TESTING

    Pre-Screening Questionnaire
  • Your health and well-being are of the up most importance and we are taking measures to keep you and our facility a safe environment for everyone.

    This questionnaire is meant for COVID-19 tests. Once you complete this questionnaire you can proceed to a clinic during testing hours. 

    If you have any questions, please:
    - Visit our website: www.MarqueMedical.com


    If this is an emergency, please alert our healthcare professionals immediately or call 911.

  • If you currently feeling active symptoms or have been exposed 3-5+ days, you can proceed to a Marque testing clinic during testing hours after completing this questionnaire. 

    Marque Clinic Testing Hours
    Orange County
    - Aliso Viejo: Daily, 11 AM - 3 PM 
    - Buena Park: Daily, 10 AM - 5 PM
    - Mission Viejo: Daily, 12:30 - 5 PM 
    - Newport Beach: Weekdays, 10 AM - 5 PM, Weekends, 9 AM - 3 PM 
    - Rancho Santa Margarita: Daily: 11 AM - 4 PM

    San Diego
    - Eastlake: Daily, 11:00 AM - 4:00 PM 
    - Grossmont: Daily, 11:00 AM - 4:00 PM 
    - Pacific Beach: Daily, 11:00 AM - 4:00 PM 
    - UTC: Daily, 11:00 AM - 4:00 PM

    Clinica Bienestar Testing Hours 
    Riverside County 
    - Riverside: Daily, 10 AM - 3 PM (Walk-up testing not available)

    LA County
    - South Gate: Daily, 10 AM - 4 PM

     

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  • 3. Within the last 14 days, have you experienced any of the following that you cannot attribute to another health condition?

  • ALL PATIENTS PLEASE READ

  • Your Covid Questionnaire phone visit is covered by most insurances and cost shares may apply. 

    If you are not experiencing symptoms or have known exposure, please note that elective Covid-19 testing will not be submitted to insurance. For more information about your healthcare plan and benefits, please contact your insurance carrier in advance.

  • Text and Voice Mail Communication: If testing is ordered by the provider from the consultation, Marque Urgent Care may text or leave me a voice message with my results at the contact details provided above. Please initial one of the options:

  • Agreement of Terms

    I agree to the terms and conditions of Marque Urgent Care, including our Notice of Privacy Practices our Virtual Health Consent. In the event I have requested services and/or testing by a medical provider of Marque Urgent Care that is not billed to my insurance, I understand that I will be responsible for all charges incurred today. I further agree that I will not submit a claim to my insurance carrier for reimbursement if I elect to not use my insurance coverage because I have been offered options for medical services and/or testing that are covered under my plan, which has been explained to me.

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  • Print this form and bring it with you to help speed things along. Remember to print before hitting the Submit button. If you don't have a printer or prefer not to it's okay, we have your information.  

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