Healthcare Cardiac Ultrasound Form

HEALTHCARE CARDIAC ULTRASOUND FORM

Patient Information

Date of Birth:    Gender:    Medical Record #:

Phone:    Alternate Phone:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Ordering Provider and Clinical Details

Provider Contact:    Clinical Indication:

Transthoracic Echocardiogram (TTE)    Transesophageal Echocardiogram (TEE)    Stress Echocardiogram    Doppler Flow Study

Contrast Echocardiography (microbubble contrast)    Other:

Vital Signs at Time of Exam

Blood Pressure (Systolic/Diastolic): /    Heart Rate:    Respiratory Rate:

Oxygen Saturation:    Weight:    Height:

Medical History

Current Medications (include dose and frequency):

Myocardial infarction    CABG    PCI/stent    Valvular disease

Congestive heart failure    Arrhythmia    Pacemaker / ICD

Procedure Consent and Acknowledgment

I, the undersigned, authorize the performance of the cardiac ultrasound examination(s) indicated above. I understand that the procedure involves external ultrasound imaging of the heart and may include Doppler assessment. I authorize necessary technical maneuvers to obtain diagnostic images. I acknowledge that the results will be interpreted by qualified physicians and entered into my medical record.

Risks and Complications: I understand that transthoracic ultrasound is noninvasive and carries minimal risk. If transesophageal echocardiography (TEE) is performed, I understand sedation and endoscopic probe insertion are required and risks include, but are not limited to, aspiration, airway or dental injury, pharyngeal or esophageal trauma, and complications related to sedation. If contrast is administered, I understand there is a small risk of allergic reaction, chest discomfort, or shortness of breath. Serious complications are rare.

Alternatives: I understand alternatives to this examination may include other imaging studies, continued clinical observation, or no testing. I have had the opportunity to ask questions and understand that I may refuse or withdraw consent at any time prior to the procedure.

I consent to Transesophageal Echocardiography (TEE) if clinically indicated and understand sedation may be required.   

I consent to administration of ultrasound contrast agents if recommended. I have disclosed all known allergies and prior reactions to contrast.   

Privacy and Release

I acknowledge that information obtained during this examination will be documented in my medical record and used for diagnosis and treatment. I authorize the release of pertinent medical information to other healthcare providers involved in my care for the purpose of diagnosis and treatment. I understand the facility will protect my health information in accordance with applicable privacy laws.

I release the performing facility, its employees and agents from liability for any complications arising from the procedure, except where caused by gross negligence or willful misconduct.

This authorization for the procedure, the use of contrast, and release of information expires on:

Acknowledgment

By checking this box I certify that I have read and understand the information above, my questions have been answered to my satisfaction, and I consent to the performance of the indicated cardiac ultrasound examination(s).

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