Microsoft word - cardio_letterhead

Heart Wellness Center Nuclear Stress Testing Consent Form My physician has recommended that I undergo a procedure known as Nuclear Stress Test. This test will show the amount of blood circulation with in my heart. The information thus obtained will help my physician evaluate the condition of my heart. The purpose of this form is to document my informed consent to the procedure. An IV will be started in one of my veins. The test consists of a radioactive isotope (Thallium, Cardiolite, or Myoview) being injected into my vein through the IV site at two intervals during the test. (Pharmacologic agents such as Persantine Lexiscan or Adenosine may be used). As a part of this test, my heart rate, blood pressure and respirations may be increased either through exercise or through the use of drugs during the Pharmacological Stress Test or Exercise Stress Test. During the performance of the test, my pulse, blood pressure and electrocardiogram will be monitored. As with any medical procedure of this nature, the test entails certain risks. These include but are not limited to the rare possibility of a serious complication occurring during the test, such as severe allergic reaction or heart attack, potentially resulting in sudden death. Every effort will be made to minimize the possibility of such complications by the preliminary examination prior to the test and by observations during the test. Further, due to the heightened security measures that have been instituted nationally by the government since 09/11/01, it may be that the small amount of radioactive material that remains in your body would trigger some of the more sensitive devices designed to detect persons carrying radioactive materials. In order to avoid any unnecessary public disruption and/or embarrassment, please carry this Nuclear consent form with you for three or more days to alert authorities, if necessary, of your recent Nuclear Cardiology test. 1. Sex: [ ] Female [ ] Male If female, are you currently pregnant, possibly pregnant or breastfeeding? [ ] Yes [ ] No Do you have any latex allergies? [ ] Yes [ ] No Date of Birth________________________________ Are you currently taking or have you taken in the last 72 hours Viagra, Vigromax, Levitra, Cialis, or any other drug with similar properties? [ ] Yes [ ] No Are there any other medications you have taken within the last 72 hours, including natural remedies, which we have not discussed? If yes list________________________________________________________ 6. Primary Care Physician’s Name______________________________________ CONSENT: I certify that my physician has explained the risks of the procedure described above; that I have had an opportunity to ask questions and that those questions have been answered; and that I voluntarily grant informed consent for the Procedure. _________________________________________________________________________________ Patient Signature _________________________________________________________________________________ Patient Address _________________________________________________________________________________ Witness

Source: http://www.heartwellnesscenter.org/wp-content/uploads/2012/08/Nuclear_stress_consent.pdf