STRESS ECHOCARDIOGRAM consent form

We look forward to welcoming you to our centre for your health needs.
For your convenience, please fill up the following form which will allow us to be prepared for your test.

Stress Echocardiogram Consent Form
RISKS FOR STRESS ECHOCARDIOGRAM TEST: There are no known risks involved in a standard echocardiogram. An echo does not emit radiation. An exercise stress test is generally considered safe, however, as exercise tests are usually performed on patients with known or suspected heart disease, it does carry a small risk of complications; for example: severe drop in blood pressure (hypotension), chest pain, collapsing, fainting, irregular heartbeat, heart attack (1-2:10,000). Every effort is made to minimise these risks. Exercise stress tests at Peninsula Heart Centre are performed by a qualified specialist doctor and a qualified cardiac nurse or technician. The test is only performed in a clinical setting that has access to emergency cardiac services should any complications arise. Please discuss any issues prior to agreeing to participate in the STRESS ECHOCARDIOGRAM
Please complete*
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- I consent to participate in this STRESS ECHOCARDIOGRAM test
- I understand the test which will be performed and have been made aware of the risks involved.
- I understand the signing of this form is voluntary and I am free to deny consent if I desire.
- Without consent, I understand that the test will not be performed.
Name*
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Date of birth*
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Signature*
Date*
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Show us that you are human to see the submit button – we specialise in?*
- Feet
- The Heart
- Teeth

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STRESS ECHOCARDIOGRAM consent form

Stress Echocardiogram Consent Form

03 9789 0088

FRANKSTON

MORNINGTON

ROSEBUD

ALBURY

03 9789 0088

FRANKSTON

MORNINGTON

ROSEBUD

ALBURY