Parent/Guardian Consent for Preventative Heart Screening
SafeBeat performs heart screening services to help identify clients with underlying heart defects. SafeBeat will conduct the heart screening, gather results, have the ECG results reviewed by a board-certified pediatric cardiologist and report the complete screening results directly back to the parent/guardian along with any consultation information, if needed. The school of the student will receive modified screening results of only “benched” or “cleared”. Student’s parent/guardian must clarify complete results to the school nurse if results are deemed “benched”. Student will not be able to continue playing sports until they have been “cleared” by the appropriate recommended medical physicians. Parent/Guardian is responsible for providing the students detailed “cleared” results to the appropriate school medical staff before being considered to continue with school sports activities.
The SafeBeat Program includes:
1. Personal Heart Health Questionnaire
2. Family Heart Health Questionnaire
3. Blood Pressure
4. Body Mass Index (BMI)
5. Electrocardiogram (ECG)
The ECG exam is non-invasive and there is no special preparation. During the ECG test, a technician will record the heart’s electrical activity by placing 10 leads on the chest (6 leads), arms (2 leads), and legs (2 leads), while student lies on their back. There is usually no discomfort associated with the test - all that is felt is the application and removal of the electrodes. Typical screening takes less than 15 minutes. No medications are given or necessary.
The data collected related to a student’s heart screening may be used in a pooled form only (no names or other personal identifiers attached) to conduct research and disseminate the findings, with the aim of advancing scientific knowledge regarding heart disease, sudden death, and improved ways to test for, diagnose or treat underlying defects. If the screening indicates a possible condition may be present, SafeBeat or its’ collaborative medical partner, may contact the parent/guardian in follow-up to clarify the results of the screening once additional testing has been performed. This information will only be used in aggregate and with no personal identifiers for the purposes of scientific research and advancing our knowledge on heart screenings. We will not sell or share your personal data with any third parties.
I acknowledge on behalf of my child that this screening is solely a screening examination, does not constitute a medical evaluation or diagnostic work-up, and does not establish a doctor-patient relationship. Though the best staff and efforts will be applied, I understand and acknowledge that screenings are not perfect; and thus, may either fail to detect a condition or disease that is present, or may at times falsely indicate a condition or disease is present when in fact it is not. I understand and acknowledge that SafeBeat’s personnel are not physicians and are not rendering medical care or services. I also understand that the SafeBeat preventative heart screening is not a standard physical nor does it replace the standard physical that the school/sport requires and/or provides. I have reviewed the Frequently Asked Questions at http://safebeat.org/screenings/faq/ to better inform me about the screening. I have also reviewed how to prepare for the screening at http://safebeat.org/screenings/how_to_prepare/ .
