Download Cardiac Stress Tests Informed Consent

PLACE LABEL HERE
CARDIAC STRESS TESTS
INFORMED CONSENT
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
Important: Do not sign this form without reading and understanding its contents.
The diagnosis requiring this procedure is:
1.
 Chest Pain
 Abnormal ECG or ETT
 Decreased exercise tolerance
 Diabetes
 Difficulty breathing/
Shortness of Breath
 Dizziness
 Elevated cardiac
enzymes
 Fainting (syncope)
 Hypertension
 Arrhythmias
 Palpitations
 Other: _____________________
The nature of the procedure is:

Exercise Stress Test –The test will be performed on a treadmill with the amount of effort
increasing slowly as the speed and slant increase until symptoms such as fatigue, shortness of
breath or chest discomfort occur, or until such time when the provider determines the test to be
complete. The patient will notify the provider of any such symptoms. Heart rate and rhythm are
constantly monitored on a special heart monitor and periodic blood pressures checked by a
cardiology stress technician.
OR
 Pharmacologic Stress Test – If it is unlikely a high enough level of exercise can be reached
for the test to be accurate, the provider may suggest a ‘medicated (pharmacologic) stress test’
using Lexiscan (regadenoson), dobutamine or adenosine. These medications will cause the
blood flow to the heart to increase as though you were exercising.
2.
The purpose of this procedure is to help the doctor in making a diagnosis and deciding on a course of
treatment.
3.
THIS TEST INVOLVES THE MATERIAL RISK OF ALLERGIC REACTION, ABNORMAL BLOOD
PRESSURE, FAINTING, CHANGES IN HEART RHYTHM AND RATE AND IN VERY RARE
INSTANCES HEART ATTACK, STROKE AND DEATH. EMERGENCY EQUIPMENT AND TRAINED
PERSONNEL ARE PRESENT TO DEAL WITH UNUSUAL SITUATIONS WHICH MAY ARISE.
ADDITIONAL RISKS: In addition to the material risks listed above, there may be other potential risks
involved in the procedure including, but not limited to the following:
Local irritation, bleeding infection and bruising at IV site, and other risks such as: _________________
__________________________________________________________________________________
4.
The likelihood of success of this procedure is:  Good
*2-17671*
FORM 2-17671 REV. 08/2012
 Fair
 Poor
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PLACE LABEL HER
CARDIAC STRESS TESTS
INFORMED CONSENT
(This form is designed to comply with the Georgia Informed Consent Law O.C.G.A. 31-9-6.1)
5.
The practical alternatives to this are:
Coronary Angiogram, Stress Echocardiogram and Other: ____________________________________
These alternatives have been discussed.
 Yes  No
6.
If I choose not to have the above procedure, by prognosis (future medical condition) may include:
 Worsening and increase in the seriousness of my condition
 Heart attack and/or stroke
 Death
 Other: __________________________________________________________________________
7.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR
ASSURANCES HAVE BEEN MADE TO ME concerning the results of this procedure.
8.
I have been given ample opportunity to ask questions and any questions I have asked have been
answered or explained in a satisfactory manner.
By signing this form, I acknowledge that I have read or had this form read, and/or explained to me in
general terms, and that I fully understand its content. All blanks or statements requiring completion
were filled in and all statements I do not approve of were stricken before I signed the form.
I hereby voluntarily request and consent for Dr. __________________________, as my physician, and any
other physician(s), and such associates, assistants or other medical personnel involved in performing such
procedure(s), to perform the procedure(s) described or referred to herein.
__________
Date
_________
Time
________________________________
Person giving consent
____________________________
Relationship to patient
Patient unable to sign because of _____________________________________________________________
Witnessed by: __________ _________
Date
Time
at the direction of
FORM 2-17671 REV. 08/2012
_______________________________________
Signature of person obtaining consent
________________________
Name of Responsible Physician
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