Consent to Examination Form

Consent to Examination and Release of Liability


We, the undersigned, parent(s) guardian of :	Patient Name (please print)

do hereby release all parties involved in providing the noninvasive single view parasternal long and short axis two dimensional screening echocardiogram from any liability associated with the performance of this examination. We (I) acknowledge that the results of this examination will identify a limited number but not all cardiac abnormalities that could result in sudden death. A copy of the test results will be provided to the school nurse as part of the physical record.


Parent/Guardian Name (please print)

Parent/Guardian Signature		Date


Please answer the following:		Circle

1. Have you ever passed out, fainted or become dizzy during exercise?		Yes or No

2. Have you ever had chest pain during exercise?		Yes or No

3. Have you ever had high blood pressure?		Yes or No

4. Have you ever been told you have a heart murmur?		Yes or No

5. Have you ever had a very fast, racing heart beat or skipped beats?		Yes or No

6. Has anyone in your family ever died suddenly before the age of 55?		Yes or No

7. Has anyone in your family been diagnosed with Marfans Syndrome?		Yes or No

These questions should be answered before the patient appears for the screening examination.

Call (615) 555-7979, ext. 2281, Monday – Friday, 7 a.m. to 4 p.m., to schedule the test with the Radiology Department.