The purpose of this Consent and Release is to provide you information about the South Asian Heart Center’s prevention programs, educational programs to help South Asians reduce their risk of heart attacks and diabetes and obtain your consent and release of liability. Participation in program is entirely voluntary. The components of the program are assessment with advanced comprehensive screening, intervention with education and counseling and lifestyle management with a personalized health coach. More information about all the components of the program can be found on the South Asian Heart Center website FAQ page.

As part of the program, the Center’s staff may suggest certain laboratory testing to be performed and will share your personal information with third party vendors to assist in analysis of health data or applicable interventions. The Center is not a health care provider and you should follow up with your personal physician regarding any laboratory results.

By clicking "I agree with these terms" below, I have reviewed the information above and consent to participation in the program as outlined in the Center’s website. I also authorize laboratory testing that may be warranted and the sharing of personal information with third party vendors as part of program participation.

By clicking "I agree with these terms" below, you agree to release and hold harmless South Asian Heart Center, El Camino Hospital, their officers, directors, employees, agents, volunteers and representatives, from any claims, liability or damages, including, but not limited to, personal injury or illness, arising in any way from your participation in this program.

I understand that I may ask questions before submitting this form.

My acknowledgement below indicates I freely consent to participate in the program and release the Center and El Camino Hospital from liability.