• Southeast Cardiovascular Associates

    Board Certified, Interventional Cardiology, Cardiovascular Disease & Nuclear Cardiology

    Rajan Kadakia MDNisheeth Goel MDManu Pillai MDMarlos Fernandes MDArvin Bansal MDNadish Garg MD
  • Date Format: MM slash DD slash YYYY
  • COVID-19 Screening and Immunization Questionnaire (Answer Yes / No)


  • Consent for COVID-19 Vaccine (JANSSEN COVID-19 Vaccine)

    I understand that this product has not been approved or licensed by FDA, but has been authorized for emergency use by FDA, under an EUA to prevent Coronavirus Disease 2019 (COVID-19) for use in individuals 18 years of age and older. The Janssen COVID-19 Vaccine EUA Fact Sheet for recipients is avaliable at https://www.fda.gov/media/146305/download. I request that the vaccine be given to me, and understand the risks and benefits of the vaccine.

    Privacy Notice

    I acknowledge that I have received the practice's Notice of Privacy Practices. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice's Notice of Privacy Practices. The Privacy Policies can be found online at https://southeastcardio.com/notice-of-privacy-practices/and at the practice location.

    Release of Information

    I hereby permit Southeast Cardiovascular Associates to release healthcare information for purposes of treatment, payment, or healthcare operations. Healthcare information may be released to any person or entity liable for payment on the patient's behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment.

    ImmTrac2 Consent

    ImmTrac2 ConsentThe Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and condential service that consolidates immunization records for public health purposes (e.g., giving all doctors treating a patient a central place to see that patient’s immunization records). With your consent, your immunization information will be included in ImmTrac2.I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in ImmTrac2, my immunization information may by law be accessed by: a Texas physician, or other health care provider legally authorized to administer vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specic individual covered under the payor’s policy. I understand that I may withdraw this consent at any time.
  • Date Format: MM slash DD slash YYYY