Consent Form

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TREADMILL EXERCISE STRESS TEST:

Your physician feels it is necessary for you to have a stress test; this test is commonly used to determine the presence of coronary artery disease, assess cardiac status after a heart attack or to assess a person’s physical capability to exercise. You will be walking on a treadmill, which will increase in speed and elevation and a licensed provider will constantly monitor your electrocardiogram and take frequent blood pressures. The test will be stopped when you are fatigued, reach a certain heart rate, develop symptoms or if you request that the test be stopped. Some possible side effects include but are not limited to abnormal blood pressure, fainting, leg cramps, changes in heart rate and very rarely, heart attack or sudden death.

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DIPYRIDAMOLE /ADENOSINE / REGADENOSON STRESS TEST:

Chemical stress testing is performed in patients who cannot achieve a target heart rate while performing physical exercise such as walking on a treadmill. The medications used to simulate exercise are called Dipyridamole, Adenosine, or Regadenoson. They cause your blood vessels to dilate. A licensed provider infuses this medication over a few minutes and your heart rate, EKG and blood pressure are monitored continuously. There may be side effects, which include but are not limited to mild shortness of breath, flushing and lightheadedness. There is risk (including heart attack and death) associated with this test but it is extremely low. Patients with asthma/wheezing may require treatment if they have additional side effects from the chemical vasodilator agents.

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NUCLEAR IMAGING:

In conjunction with the exercise or Dipyridamole/Adenosine/Regadenoson stress test, you will be given two injections of radioactive material (Tc99m Myoview) through the intravenous line we will put in your hand or arm, which allow us to take images of your heart on a special gamma camera. Images are obtained after an initial ‘rest’ injection, the 2nd set of images are acquired after the radioactive material is administered during the stress test. In the course of performing this test, the radioactive material(s) used are potentially harmful to a developing fetus and/or nursing child. If you know or suspect you are pregnant or if you are breast-feeding a child, please inform the technologist at this time.

 

By signing this consent form, you are authorizing the licensed provider to do whatever is necessary should unforeseen conditions arise during the test. Emergency personnel and equipment are readily available in the unlikely event they are needed.

 

I am free to withdraw my consent and terminate the test at any point, understanding that this may result in incomplete test results. All information will be treated confidentially and will be treated as part of my medical record. This information may be used for statistical purposes while retaining my right to privacy.

CONSENT:

I have read and understand the above statements and have had an opportunity to ask questions.  I hereby willingly consent to:             

_X_ Cardiac Stress Test -and- _X_ Nuclear Imaging

 

X____________________________________________________            X______________________

Patient/Guardian Signature                                                                        Date

 

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Print Name

 


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Jon Ammar,
Mar 20, 2015, 6:08 AM