Marque Medical Patient Information

1
Patient Information - Who is Being Seen Today?* This field is required.Are you a new or an established patient? (Please be sure you select the correct field or we may not be able to hold your spot in line. Thank you!)
New
New
Established (only if the patient themselves have completed a visit at Marque Urgent Care before)
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Patient's Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number
Area Code
Phone Number
7
Email
example@example.com
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Date of Birth* This field is required.
Month
Day
Year
9
Gender* This field is required.
Female
Male
N/A
10
Driver License* This field is required.For minors, please upload the guarantor's ID
11
Preferred PharmacyIf we prescribe medicine, where would you like it sent? Please be specific so we send it to the right place.
12
Insurance Information* This field is required.How would you like to handle your visit today? (Please be sure you select the correct field or we may not be able to hold your spot in line. Thank you!)
My Insurance (applicable cost shares will apply)
No Insurance, Pay $129 (does not include the cost of additional services, such as Covid-19 testing if needed)
Employer Paid Service (Work Comp not eligible for virtual medicine)
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Front of Insurance Card -* This field is required.
14
Back of Insurance Card* This field is required.
15
Subscriber's Relationship to Patient* This field is required.
Self
Self
Mother
Father
Spouse
Caregiver
Other
16
Subscriber's Name* This field is required.
First Name
Last Name
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Date of Birth of Subscriber* This field is required.
Month
Day
Year
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Is this for a new injury or existing work comp injury? * This field is required.
New injury evaluation
Existing injury treatment
Important: Please provide your employer name below
19
Name of Employer
20
Employer Contact InformationPlease provide the name of your employer, a contact person there, and a contact phone number
21
Employer Code (if provided)
For employer-sponsored plans
22
Primary Insurance Co
23
Policy No
24
The Subscriber's Relationship to Patient
Ex: Patient, Parent, Caregiver
25
Group No
If Applicable
26
Do You Have Secondary Insurance?
No, just the insurance above
No, just the insurance above
Yes
27
Secondary Insurance Name and Member ID Number
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Policy No
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Group No
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Subscriber's Name
First Name
Last Name
31
Please read our Consent to Virtual Medicine Policy
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Agreement of Terms* This field is required.
I agree to the terms and conditions of Marque Medical including our Virtual Consent Agreement provided above
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Northgate Store Number or Location* This field is required.
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By clicking submit you are agreeing to the terms and conditions of Marque Medical including our COVID-19 testing policies and our Virtual Medicine Consent Agreement. A copy of our Patient Privacy Practices can be found at www.marquemedical.com.* This field is required.Text and Voice Mail Communication - Required consent for your visit today
In the event that testing is ordered by the provider from the consultation, Marque Medical may text or leave me a voice message with my results at the contact details provided above.
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Signature* This field is required.
Clear
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