• Consent for Calcium Scoring

  • I,
  • , authorize Southeast Cardiovascular Associates to administer and conduct a Cardiac Calcium Scoring CT exam. I have undergone an interview and
  • physical exam with a physician or a physician’s representative and this exam has been recommended.
  • A Cardiac Calcium Scoring exam is a non-invasive procedure, done on a CT (Computed Tomography) scanner for measuring and reporting coronary artery calcification scores. Calcium deposits do not correspond directly to the percentage of narrowing of the arteries. They can, however, correlate directly to the amount of coronary plaque, and to the risk of future coronary disease. These calcium deposits usually begin to form years before any symptoms develop. Early detection and modification of your personal risk factors, such as smoking and cholesterol level, can slow the progress of coronary disease and potentially impact your risk of having a heart attack.
  • A low score suggests a low likelihood of coronary artery disease but does not exclude the possibility of significant coronary artery narrowing. The results should be discussed with your physician who will consider other risk factors such as age, gender, family history, diabetes, smoking or high cholesterol levels.
  • PREPARATION:
    1. Metal objects must be removed from the chest area. Please do not wear shirts with metal buttons or zippers. Women are advised to wear a sports type bra or a bra that does not contain an underwire closure. Personal body piercing jewelry must be removed prior to arrival.
    2. Southeast Cardiovascular Associates requires the payment of $99.00 prior to checking in for your Calcium Scoring appointment. You will be provided a receipt upon payment that can be submitted to your insurance company for possible reimbursement. Reimbursement is not guaranteed.
    3. Inform us immediately if you are pregnant, suspect you may be pregnant or are a nursing mother.
  • CONSENT:

    The information obtained is treated as confidential and will not be released to any person without my written consent. This information may, however, be used for statistical or scientific purposes without violating my right to privacy.

  • I have read the above and consent to proceed with this test. In the unlikely event that injury or complications result, I permit the physician and other personnel to administer such treatment, including hospitalizations, as may be necessary. I will not hold the physicians or staff of Southeast Cardiovascular Associates responsible.

  • FEMALE PATIENTS:

    By signing, I confidently state that I am not currently pregnant or breastfeeding.

  • MM slash DD slash YYYY