In order to evaluate the ability of my heart to respond to exercise, I voluntarily agree to undergo an exercise stress test under the supervision of the Health by Design physicians.
The test which I will undergo will be performed with the amount of effort increasing every three minutes or at the preference of the physician. This increase in effort will continue until symptoms such as fatigue, shortness-of-breath or chest discomfort may appear. During the test and afterward (during the recovery period), the supervising physician and nurse will keep my pulse, blood pressure and electrocardiogram under surveillance.
There exists the possibility of certain changes occurring during the test. They include abnormal blood pressure, fainting, disorders of the heart beat (too rapid, too slow, or ineffective), and the potential risk for an acute myocardial infarction (heart attack). Every effort will be made to minimize them by the preliminary examination and observations during testing. Emergency equipment and trained personnel are available to deal with unusual situations should they arise. The information which is obtained will be created as privileged and confidential.
I have read the above and give my consent to proceed with the test and will not hold the personnel involved or Health by Design responsible if untoward events or injury results.