Westwood Cardiology Associates, P.A.

Patient Name: _____________________________________________
                      (Last, First, Middle)

I hereby consent to a:
[ ] Stress Test

[ ] Stress Echo

I understand that this test has been ordered by my physician to help diagnose cardiopulmonary disease. I voluntarily consent to perform this test. Before undergoing the stress test, I will be examined and my chart reviewed by a physician from Westwood Cardiology Associates to determine that the test is appropriate.

The test will be performed on a treadmill with the amount of effort increasing gradually. The test will be discontinued upon attaining the target heart rate or exercise goal. The test may also be discontinued if I develop symptoms such as fatigue, shortness of breath or chest discomfort. The physician may stop the test if there are changes on the electrocardiogram or if irregular heart rhythms develop. The test will be performed by a physician or a trained cardiac nurse under the supervision of a physician. During testing, the electro-cardiogram, pulse, and blood pressure will be monitored.

There is the possibility that certain changes may occur during the test. These include the development of chest pain, a drop in blood pressure, or irregular heart rhythms. Very rare complications of stress testing have included heart attack or death. Every effort will be made to minimize any chance of any adverse event by the preliminary screening and the close observation during the test. Emergency equipment and trained personnel are available to deal with any situation which may arise.

I have read the foregoing and I understand it and any questions which may have occurred to me have been answered to my satisfaction.





Physician Supervising the Test