Getwell Urgent Care Merced CA Form

COVID-19 Test Scheduling and Registration

Most insurances accepted

Please confirm that you are trying to register for Getwell Urgent Care in Merced, CA

Yes No

Have you been to Getwell Urgent Care before?

Yes No

How did you hear about us?

Billboard

Facebook

Instagram

Google

Other

Is this COVID test for Travel or Employment?

Yes No

If you answered 'Yes' to above question, this will be a 'Self Pay' visit

Agree Disagree

Are you traveling to the State of Hawaii?

Yes No

Do you have any COVID-19 Symptoms (Fever/Chills, Cough, Shortness of Breath, Fatigue, Muscle or Body Aches, Headache, Loss of Taste of Smell, Sore Throat, Congestion/Runny Nose, Nausea/Vomiting, Diarrhea) OR Do you think you were exposed to someone with COVID-19?

Yes No

If you answered 'No' to above question, this will be a 'Self Pay' visit

Agree Disagree

First Name:

Last Name:

Date of Birth:

Phone Number:

Email:

Address:

Street Address Line 2:

City:

State / Province:

Postal / Zip Code:

Gender

Male

Female

Decline to Specify

Will this visit be billed to insurance, paid by an employer, or a Self Pay?

Bill insurance

Employer

Self Pay (If this is Travel or Employment related, No COVID symptoms, No exposure)

Primary Insurance (For Self Pay, Select 'Other' and type in 'Self Pay')

BCBS

Aetna

Cigna

Medi-Cal

United Health Care

Tricare

Other

Primary Insurance Subscriber # (For Self Pay, type in '123456'):

Insurance Group # (For Self-Pay, type in 'NA'):

Relationship to Insured (For Self-Pay, select 'Self')

Self

Spouse

Child

Subscriber Name:

Do you have secondary insurance?

Yes No

Secondary Insurance

BCBS

Aetna

Cigna

Medi-Cal / Cal-Optima

United Health Care

Tricare

Other

Secondary Insurance Subscriber/Member #:

Relationship to Insured (Secondary)

Self

Spouse

Child

Other

Subscriber Name:

Current Medications:

Past Medications:

Allergies: