COVID-19 Consent Form – Southeast Cardiologist

Houston 281-506-8720
Pearland 281-506-8720
contact@southeastcardio.com

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Southeast Cardiovascular Associates
Board Certified, Interventional Cardiology, Cardiovascular Disease & Nuclear Cardiology
Rajan Kadakia MD Nisheeth Goel MD Manu Pillai MD Marlos Fernandes MD Arvin Bansal MD
Name:*
Sex*
- Male
- Female
- N/A
Date of Birth:*
MM slash DD slash YYYY
Emergency Contact Name:*
Emergency Contact #:*
Insurance Name:*
Insurance ID:*
Insurance Group:*
COVID-19 Screening and Immunization Questionnaire (Answer Yes / No)
In the past 2 weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?*
- Yes
- No
In the past 2 weeks, have you had known exposure with anyone who has tested positive to COVID-19?*
- Yes
- No
Have you had new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting's or diarrhea?*
- Yes
- No
Do you have any known allergies?*
- Yes
- No
Have you ever had a serious reaction or fainted after receiving any vaccination?*
- Yes
- No
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?*
- Yes
- No
For women: Are you pregnant or are you planning on becoming pregnant during the next month?*
- Yes
- No
Select a category (Check one)*
- Phase 1A - A Healthcare worker?
- Phase 1B - Over 65 or over 18 and with a health condition which puts you at risk for severe COVID-19?
- Federal Directive - Teacher?
- Wait List - Please call me if there is a no-show to prevent wastage of a COVID-19 vaccine dose (Please note you will receive a text message, and will be requested to come to our clinic asap)?
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.
Signature:*
Date:*
MM slash DD slash YYYY