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      • Autonomic Nervous System Testing
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      • P Wave Signal Averaging
      • Carotid Doppler
      • Lipid Profile
      • EECP
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      • Vascular Testing
      • Signal Average EKG
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Request An Appointment

0323 - Stress Cardiolyte Consent

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Time:(Required)
:

Stress Cardiolyte Instructions: Nothing to eat or drink (except for water) for 4-6 hours prior to the exam. No caffeine products for 24 hours prior to the exam (ex: coffee, tea or sodas). Wear comfortable clothes and shoes. Take your medications except for your high blood pressure medications as instructed by the physician. This exam will take approximately 2 hours. You will be able to drive afterwards (If you are able to drive yourself). Please call (214) 504-9942 if you have any questions regarding this procedure.

Consent for Stress Cardiolyte: I hereby authorize Dr. Amer Suleman to perform the stress test. In order to determine an appropriate plan of medical management, I hereby do consent to voluntarily engaging in a stress test with to without the injection of radioactive isotope to determine the state of my heart and its circulation. The test will consist of being attached to an EKG monitor while walking on a treadmill or receiving pharmacologic stress agent. If the test is to be aided by an injection of a radioactive isotope, the technologist will start an IV in the vein. The exercise will be continued until the necessary heart rate is achieved or until symptoms occur.

Female Patient Screening (applicable to females that are 11-55 years of age):

Is there any possibility you could be pregnant?
If "NO", please check appropriate:
MM slash DD slash YYYY
Are you currently breast feeding?

No Show Responsibility:The stress cardiolyte involves us ordering dye that must be opened before you arrive. If you do not show up for this appointment, the medication will be unusable. Please give us a 24-hour notice if you will not be able to make the appointment. If you do not show up for this appointment and no notification is received within 24 hours prior to the test, then we will be billing you for the cost of the nuclear medication ordered. The cost of the medication is as follows: TC 99m Myoview $84.00 Please let us know if you have any questions regarding this policy.

I have read and understand the above information.

MM slash DD slash YYYY
The Heartbeat Clinic – Specialized POTS Care in Dallas & McKinney

At The Heartbeat Clinic, we are dedicated to providing expert care for Postural Orthostatic Tachycardia Syndrome (POTS) and related autonomic nervous system disorders.

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  • Mckinney Office: 4541 Medical Center Dr, McKinney, TX 75069
  • Dallas Office: 9319 Lyndon B Johnson Fwy STE 100, Dallas, TX 75243
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Disclaimer: The information provided here is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. While we strive to ensure accuracy, the content may not always reflect the latest medical developments. Always consult a qualified healthcare provider for any medical concerns or before making health-related decisions. The Heartbeat Clinic is not liable for any actions taken based on the information provided here. For any changes to the content or recommendations, please email us at [email protected]

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