COVID-19 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

Name of Patient *

First Name Last Name

Gender *

MALE FEMALE

New Patient to Marque? *

YES, NEW PATIENT NO, EXISTING PATIENT

What is your weight? *

What is your height? *

Patient Date of Birth *

Date

Phone Number *

Please enter a valid phone number.

Patient Email Address *

example@example.com

Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

1. Are you currently feeling any symptoms that may be related to COVID-19? *

YES NO

When did you start feeling symptoms (how many days ago)?

2. Is this testing for non-symptomatic reasons only such as work clearance, school clearance, or travel? *

YES NO

3. If exposed and asymptomatic, has it been at least 3-5 days since your known exposure date? *

YES NO, please wait for 3-5 days since exposure to ensure accurate results N/A, I am symptomatic

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

A temperature at or above 100.4° or the sense of having a fever? *

YES NO

Runny nose *

YES NO

Fatigue *

YES NO

Sneezing *

YES NO

Night sweats *

YES NO

Headache *

YES NO

Loss of taste/smell *

YES NO

Sore throat *

YES NO

Cough *

YES NO

Shortness of breath *

YES NO

Diarrhea *

YES NO

Muscle aches *

YES NO

4. Have you had close contact without the use of appropriate protection (such as a mask) with someone who is currently sick with confirmed COVID-19?* (Note: Close contact is defined as within 6 feet for more than 15 cumulative minutes in a 24 hour period) *

YES NO

How many days ago were you exposed?

5. Are you on any current medications? *

YES NO

What medications are you currently taking?

6. Are you allergic to any medications? *

YES NO

What medications are you allergic to?

7. Do you have any known medical conditions (such as high blood pressure, diabetes, asthma, or other chronic medical conditions)? *

YES NO

What known medical conditions do you have?

8. Will you be using insurance today for your testing? *

YES (please provide info below, cost shares may apply) NO, self-pay (we still need your insurance info for the doctor consult, cost shares may apply) NO, my employer is paying

Name of Employer and Contact Person *

9. Are you the patient being seen today? *

YES, I am the patient NO, I am not the patient

If you are not the Subscriber, what's your relationship to the insured?

Self Mother Father Spouce Caregiver Other

Member ID from Insurance Card

Insurance Card - Front

Insurance Card - Back

10. What type of testing are you requesting? *

Rapid Molecular RT-PCR (same day reporting, not submitted to insurance: $215) Rapid Antigen (same day reporting, not submitted to insurance: $69)

11. Please indicate your COVID-19 vaccination status: *

I have been fully vaccinated for COVID-19 I have not been fully vaccinated for COVID-19 I prefer not to specify my vaccine status

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:

Do you authorize Marque Urgent Care to leave a voice or text message at the number provided? *

Yes, I authorize No, I do not authorize

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.

Patient Signature (or parent/guardian/other authorized person if the patient is a minor, mentally incompetent, or physically unable to sign) *

Clear

Date *

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.

WALK-UP COVID TESTING

ALL PATIENTS PLEASE READ