Ekg Screening Permission Form

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Knoxville Pediatric Cardiology
Electrocardiogram (EKG/ECG) Screening
___________________________________________________________________________________________________________
Required Demographics (Please Print)
Participant Name: ___________________________________________________________ Birth date: ____ /______/_____ Age: _______Sex: M F School: ________________
(First)
(Middle)
(Last)
Mailing Address:
____________________________________________________________________________________________________________________________________________________
City
State
Zip Code
Father: __________________________________________Mother:__________________________________________Legal Guardian: ____________________________________
(First)
(Last)
(First)
(Last)
(First)
(Last)
Participants Primary Phone: ( _____ )
___
­____________
Participants Secondary Phone: (
_____ )
___
­____________
Participants Primary Care Physician: __
___
_____________________
(Above information will be used only for processing, mailing, and contacting individuals of results when indicated, we ask that you be as complete as possible)
____________________________________________________________________________________________________________________________________________________
I give my permission for my child to participate in the Knoxville Pediatric Cardiology Screening program that will be offered in addition to
the Knoxville Orthopaedic Clinic pre participation physical exams being held on Saturday, April 26, 2014. This cardiology screening
involves my child receiving an electrocardiogram (EKG or ECG) which is a non‐invasive test that measures the electrical activity of the
heart and can detect certain heart abnormalities that could lead to sudden cardiac death.
I understand that my child’s participation in the Knoxville Pediatric Cardiology EKG Screening is intended to identify heart abnormalities
which may affect their health during physical activities. I assume all risks associated with my child’s participation in the EKG screening.
All such risks being known and appreciated by me and having read this waiver any and all claims I may have for damages against
Knoxville Pediatric Cardiology and any and all individuals associated with this screening, their heirs, representatives and successors and
assignees for any and all injuries suffered by my child in connection with this screening even though that liability may arise out of the
negligence or carelessness on the part of those named in this waiver.
I understand that Knoxville Pediatric Cardiology or participating high schools will make their best efforts to keep my child’s health
information confidential pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) its related rules and
regulations and other state laws. In the event my child’s EKG indicates that further evaluation is needed, Knoxville Pediatric Cardiology
may contact me for additional information.
I acknowledge that I have read this permission form and waiver and understand the risks associated with my child’s participation in the
Knoxville Pediatric Cardiology EKG screenings. 
.
Agreement to participate in Electrocardiogram (EKG/ECG) Screening 
Date: ____________ 
Signature of Participant (
):_____________________ 
If age 18 or older
Date: ____________ Signature of Parent/Guardian: _____________________ Parent/Guardian (
):_____________________ 
Please Print
(The below section reserved for KPC screening staff only) 
Electrocardiogram performed by:_____________________________

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