Consent Form For Tenafly School District Screening
You, the undersigned, give consent for your child to voluntarily participate in the Heart Screening hosted by Simon's Heart (hereinafter referred to as "Screening Organization") as described in this Informed Consent Form. You understand that the Heart Screening will consist of an electrocardiogram (ECG) and a medical history form. Other exams may be conducted: blood pressure, height and weight, auscultation (murmurs), and/or an echocardiogram (ECHO). The Heart Screening is not intended to serve as formal clearance for sports participation. Clearance for sports must be obtained from your child's physician.
Part One: Definitions
An electrocardiogram is a non-invasive test that measures the electrical activity of the heart and can detect certain heart abnormalities leading to sudden cardiac death. Your child will have twelve stickers (electrodes) placed on his/her chest, arms and legs. These stickers are connected to wires and the wires are connected to the ECG machine. It will read the electrical activity of your child's heart.
An echocardiogram is a non-invasive test that uses sound waves to create a moving picture of the heart that can detect heart abnormalities. This test is only used if the medical team wants to take a closer look at your child's heart. This test requires a small amount of gel to be placed on your child's chest. The medical practictioner rubs a wand on your child's chest to obtain an image of the heart. It is very similar to a pregnancy sonogram.
Part Two: About the Screening
The Heart Screening is administered by health professionals, which may include cardiologists, pediatricians, family doctors, technicians and nurses. The results from the ECG and ECHO (if completed) are interpreted by licensed and qualified medical professionals. You acknowledge that the Heart Screening does not establish a treatment relationship between your child and Screening Organization or the licensed healthcare providers administering the Heart Screening for and on behalf of the Screening Organization.
Part Three: Your Responsibilities
You agree to complete a medical history form on behalf of your child that will be reviewed by the medical team performing the Heart Screening. Many of the conditions that lead to sudden cardiac arrest and death are genetic and have warning signs. Therefore, You acknowledge and agree that the information contained in your child's medical history form is a very critical piece to the screening process. The information that You provide on the accompanying forms will be complete and correct to the best of your knowledge.
You will receive the Heart Screening results via email. You understand and acknowledge that your child's heart is growing, and that his/her heart is changing too. As such, You acknowledge that the information You receive from the Heart Screening reflects the condition of your child's heart today. It does not constitute a conclusive diagnosis of your child's heart health or physical condition, and is not intended to serve as a replacement for treatment and checkups with your child's primary care physician or other provider.
You will continue to monitor your child's heart and become familiar with the warning signs and symptoms of sudden cardiac arrest. You acknowledge and agree that it is your duty to provide and discuss any abnormal results with your child's physician as soon as possible and/or follow up with a pediatric cardiologist.