Consent to Examination and Release of Liability
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.
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.