COVID-19 Testing for Student-Athletes

Your health and well-being are of the up most importance and we are taking measures to keep you and our medical staff safe.

If your student-athlete needs a COVID-19 test prior to participating in athletic events, we are offering rapid Antigen testing at our clinics specifically for high school student-athletes. The rapid Antigen or PCR test will not be submitted to insurance, since insurance is not picking up the cost for non-symptomatic testing. If your student-athlete

The following pricing for high-school students and payment is due at the time of service is as follows:
1. On-site Rapid PCR: $189
2. On-site Rapid Antigen: $89
3. Lab-sent PCR through WestPacific: $149

Once you fill out this form you can proceed to a Marque Urgent Care clinic to be tested (PLEASE NOTE: all Marque clinics are testing for COVID-19 EXCEPT our Rancho Santa Margarita clinic located in Orange County at this time). No appointment is necessary.

When you arrive at a clinic, please call the front desk (extension numbers are at the bottom of this form) or go to the lobby doors and let them know you are here for a COVID-19 test needed to participate in high school sports. The test will be conducted in your car, so please remain in your car and a Marque team member will come to you.

Rapid results come back same-day (typically within a few hours) and samples are collected at a Marque clinic. Lab-sent tests are back within a few days and we will call and send you results when they are sent back to us.

PLEASE NOTE BELOW

Test results will be emailed to the email address you provide below. Results are sent as a .Zip file and WILL be password-protected. The password is the student's date of birth in this format: MMDDYY. Some patients find it difficult to download .Zip files on smartphones, so try switching to a tablet or computer. If you have any questions, please call 949-617-3995, text 949-390-5202, or email patientcare@marquemedical.com.

Name of Student Being Tested *

First Name Last Name

Gender *

MALE FEMALE

New Student to Marque? *

YES, NEW PATIENT NO, EXISTING PATIENT

Student weight? *

Patient height? *

Student Date of Birth *

Date

Best Contact Number *

Please enter a valid phone number.

Best Email Address *

example@example.com

Home 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. Name of High School *

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?

Rapid results come back same-day (typically within a few hours) and 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.

PLEASE AGAIN NOTE: We will email test results to the address you provide below. Results are a .Zip file and will be password-protected. The password is the student's date of birth in this format: MMDDYY. Some patients find it difficult to download .Zip files on smartphones, so try switching to a tablet or computer. If you have any questions, please call 949-617-3995 or email patientcare@marquemedical.com.

ORANGE COUNTY CLINIC COVID-19 TESTING HOURS and EXTENSIONS
- Aliso Viejo: Ext. 1301/1302, Testing Hours: Monday-Sunday, 8:30 AM - 3 PM
- Buena Park: Ext. 1901/1902, Testing Hours: Monday-Sunday, 9 AM - 4 PM
- Mission Viejo: Ext. 1801/1802, Testing Hours: Monday-Tuesday, 2 PM - 8 PM and Wed-Sun, 12:30 PM - 6 PM
- Newport Beach: Ext. 1101/1114, Testing Hours: Monday-Friday, 8 AM - 6 PM and Sat-Sunday, 9 AM - 4 PM
- Rancho Santa Margarita: Not testing at this time

SAN DIEGO CLINIC COVID-19 TESTING HOURS and EXTENSIONS
- Eastlake: Ext. 1401/1402, Testing Hours: Monday-Saturday, 11 AM - 6 PM and Sunday, 10:30 AM - 4 PM
- Grossmont: Ext. 1501/1502, Testing Hours: Monday-Saturday, 11 AM - 6 PM and Sunday, 10:30 AM - 2:30 PM
- Pacific Beach: Ext. 1701/1702, Testing Hours: Monday-Saturday, 10:30 AM - 5 PM and Sunday, 10:30 AM - 3:30 PM
- UTC: Ext. 1601/1602, Testing Hours: Monday-Saturday, 11 AM - 5:30 PM and Sunday, 10:30 AM - 4 PM

The following pricing for high-school students and payment is due at the time of service is as follows:
1. On-site Rapid PCR: $189
2. On-site Rapid Antigen: $79
3. Lab-sent PCR through WestPacific Labs: $149

Once you fill out this form you can proceed to a Marque Urgent Care clinic to be tested (PLEASE NOTE: all Marque clinics are testing for COVID-19 EXCEPT our Rancho Santa Margarita clinic located in Orange County at this time). No appointment is necessary.

When you arrive at a clinic, please call the front desk (extension numbers are at the bottom of this form) or go to the lobby doors and let them know you are here for a COVID-19 test needed to participate in high school sports. The test will be conducted in your car, so please remain in your car and a Marque team member will come to you.

Rapid results come back same-day (typically within a few hours) and samples are collected at a Marque clinic. Lab-sent tests are back within a few days and we will call and send you results when they are sent back to us.

Do you authorize Marque Urgent Care to test your child for COVID-19 and to email results to the address on file. *

Yes, I authorize No, I do not authorize

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

ALL PATIENTS PLEASE READ