Language
  • English (US)
  • Español
  • COVID-19 (SARS Cov-2)

    Active 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. Please answer the following questions below to help us assess the need for COVID-19 testing. Our Providers will review this information and order a diagnostic test if they determine you may be infected with COVID-19 in their medical judgement. Once you fill out this questionnaire you can proceed to a clinic to be tested (all Marque clinics are testing for COVID-19 except our Rancho Santa Margarita clinic at this time). No appointment is necessary.

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

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

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

    Marque Clinic Testing Hours
    Orange County
    - Aliso Viejo: Daily, 8:30 AM - 3 PM
    - Buena Park: Daily, 9 AM - 4 PM
    - Mission Viejo: Mon-Tues, 12:30 - 7 PM and Wed - Sun, 12:30 PM - 6 PM
    - Newport Beach: Weekdays, 8 AM - 6 PM, Weekends, 9 AM - 4 PM
    - Rancho Santa Margarita: Not Testing at this time

    San Diego
    - Eastlake: Mon-Sat, 11 AM - 2:30 PM, 3 PM - 6 PM and Sun, 10:30 AM - 4 PM
    - Grossmont: Mon-Sat, 11 AM - 2:30 PM, 3 PM - 6 PM and Sun, 10:30 AM - 2:30 PM
    - Pacific Beach: Mon-Sat, 10:30 AM - 2 PM, 2:30 PM - 5 PM and Sun, 10:30 AM - 3:30 PM
    - UTC: Mon-Sat, 11 AM - 2:30 PM, 3 PM - 5:30 PM and Sun, 10:30 AM - 4 PM

    You do not need an appointment. When you arrive at the clinic you can check in at the front door, call our hotline at 949-617-3995 or text us at 949-390-5202 and let us know that you're here, what car you're in and if you want a rapid or lab-sent test.

  • ALL PATIENTS PLEASE READ

  • If you are using insurance for lab-sent testing, we will submit your claim to your plan. Applicable deductibles and co-payments may be required depending on your plan's benefits. Please complete the insurance information in the event there is a required deductible or co-pay. We will need this informaiton for the provider evaluation and consult even if you are requesting a rapid testing option. 

    During this time, many insurance plans are waiving cost-sharing for COVID-19 evaluations and lab testing if the Marque Clinician determines you are symptomatic or at high-risk for exposure (typically defined as less than 6 feet for more than 15 consecutive minutes without a mask) with an infected COVID-19 person. Marque offers both lab-sent and on-site rapid testing.

    If you choose to use your insurance for testing, we will send your sample to a contracted outside lab and results are back within 1-7 days. Please consult your personal benefit plan details for any out-of-pocket costs. If you choose a rapid testing option, those are not submitted to insurance and payment is due at time of service. Rapid results are processed in 15-30 mins and reported shortly thereafter. All samples are collected at a Marque clinic. If you do not have or plan to use your insurance, payment is due at time of service.

  • 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.

  • Clear
  •  -  -
    Pick a 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.  

  •  
  • Should be Empty: