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: EKG HEART SCREENING PERMISSION AND WAIVER
Screening Date Participants Last Name First Name
Date of Birth:_________________________________________
Screening Location: __________________________________
About the Screening:_______________ is offering a no cost heart screening program for youth ages 14-24. The heart screening program includes a focused history and physical examination, as well as an electrocardiogram (also known as an EKG or ECG) which is a painless, non-invasive test that evaluates the health of a heart by identifying selected heart abnormalities. Many abnormalities of the heart can potentially cause sudden cardiac death. The EKG/ECG screenings do not always detect cardiovascular abnormalities when present, and not all potentially fatal heart abnormalities can be detected by this screening.
Risks: This screening does not hurt and is non-invasive. No needles or sedation are used. The electrode patches may cause skin irritation.
Participation: I understand that my decision to participate in this screening is voluntary. I understand that the screening is intended to identify heart abnormalities which may affect my health during physical activities. I understand that the test results do not represent or imply that I may or may not be at risk for cardiac complications. I also understand that this screening does not constitute a complete medical examination or diagnosis and that this screening does not establish a physician patient relationship as that term is typically defined. By agreeing to my participation in this program, I recognized, understand, and accept all risks and responsibilities associated with and resulting from it.
Confidentiality: As part of this screening, I agree that physicians, medical personnel, and staff can access my medical records from this screening. I agree that Hilo Medical Center, East Hawaii Medical Group and their physicians, medical personnel, and staff can contact me in regards to my participation in this screening program. I also authorize East Hawaii Medical Group to use this information, including the results of this screening test, for statistical evaluation; in doing so, I understand that the information will not be individually identified to me in any recognizable way. I understand Hilo Medical Center will treat my medical records from this screening in a confidential manner and in accordance with applicable laws and regulations, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Test Results: I understand that the test results will be read by a Hilo Medical Center or East Hawaii Medical Group cardiologist who may advise me to seek follow-up testing and treatment with another physician. I understand that these are general cardiologists and not specialists in pediatric cardiology. I recognize and acknowledge that I am personally responsible for taking appropriate follow-up action upon receipt of test results and I am personally responsible for deciding whether to pursue further care and treatment. It is my responsibility to discuss the results of the screening with my primary care physician.
If I do not have a primary care physician, I understand that I am strongly encouraged to engage the services of a primary care physician to review any abnormal screening results and to determine my follow-up healthcare needs. The physicians conducting these tests are not primary care physicians, and therefore assume no responsibility or liability for my follow-up care. If I receive notice of an abnormal screening result, I understand that any delay on my part to follow-up with my primary care physician in a timely manner could result in adverse health consequences. I also understand that future physician encounters and tests are not considered part of this screening and I acknowledge I am financially responsible for follow-up care.
Agreement, Consent, and Waiver: I have read this permission and waiver and understand and accept all risks and responsibilities associated hereunder. I have had the opportunity to ask questions and my questions have been answered in a satisfactory manner. I have been informed as to the purpose of this screening and freely consent to my participation in the screening.
By signing this consent and waiver, I hereby agree to waive any and all claims against Hawaii Health Systems Corporation, Hilo Medical Center, East Hawaii Medical Group, and any and all of their physicians, directors, officers, employees, and agents (collectively Indemnified Parties), and I further agree to indemnify and hold harmless the Indemnified Parties from and against any claim, loss damage, cost, expense (including reasonable attorneys fees) or liability arising out of or related to the failure of the screening and/or the corresponding interpretation of the results to detect heart disease, abnormalities or any other illness.
Participants Name: ___________________________________________________________ Age:______________
Primary Care Physician: __________________________________________
Address: ____________________________________________________________________________________
Telephone: ______________________________________________
Signature: _______________________________________________ Date: ____________________________
1190 Waianuenue Ave., Hilo, Hawaii 96720
Phn: 808-932-3000 | Fax: 808-974-4746
Hawaii Health Systems Corporation
Sports Cardiology Program
East Hawaii Health Clinic
1190 Waianuenue Avenue
Hilo, HI 96720
PHONE (808) 932-3000
FAX (808) 974-4746
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2021-05-13T16:01:44-10:00
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2021-05-13T16:01:44-10:00
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