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 that are ONLY for traveling purposes. If you need a COVID-19 test for anything other than for travel, please first schedule a Virtual Visit to get an order from a Marque provider.

Once you fill out this questionnaire you can proceed to a clinic during testing hours (all Marque clinics are testing for COVID-19 except our Rancho Santa Margarita clinic at this time). No appointment is necessary and testing hours are at the bottom of this form.

If you have any questions, please:
- Call: 1-877-693-6266
- Text: 949-390-5202
- Visit our website: www.MarqueMedical.com

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

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. 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

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?

Will you be using insurance today for your testing? *

YES (please provide info below) NO, self-pay (we still need your insurance info for the doctor consult and evaluation which is covered under most plans) NO, my employer is paying

Name of Employer and Contact Person *

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

What type of testing are you requesting? *

Lab-sent Molecular RT-PCR (1-7 day result reporting) Rapid Molecular RT-PCR (same day reporting, not submitted to insurance) Rapid Antigen (same day reporting, not submitted to insurance)

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.

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:

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.

COVID-19 Testing for Travel

ALL PATIENTS PLEASE READ