Stress Consent Form 

What risks and complications should patients be informed about when undergoing stress perfusion testing?  
I am not an attorney and do not pretend understand the nuanced legal requirements for informed consent applicable to every state, region, or nation. The sample consent form provided below is my concept of the minimum reasonable information that should be provided to patients deciding whether to undergo this test. As always, consultation with your local health care attorney and/or relevant regulatory board(s) should be obtained prior to creating a consent form suitable for use at your facility.
SAMPLE CONSENT FORM FOR
CARDIAC MRI STRESS TESTING
Your physician has recommended that your cardiac MRI scan include a Stress Perfusion Study to examine the blood supply to your heart. For this you will receive a medication (dobutamine, atropine, adenosine, or regadenoson) through your IV that will increase the blood flow to your heart and make it beat faster.  As with any medication, a small chance exists that you may have a reaction to it. 

Risks and complications of a Stress Perfusion Study include:
  • Minor/temporary side effects. These include warmth, flushing, chest discomfort, headache, nausea, dizziness, or pain at the injection site.
  • Shortness of breath. Usually mild and self-limited, but may become severe enough to require treatment with medications.
  • Chest pain/angina. Usually mild but may be severe enough to require treatment. In rare cases it may even progress to a heart attack.
  • Change in heart rate, rhythm, or blood pressure. The drugs you receive are supposed to make your heart beat faster as an essential part of the Stress Study. However, your heart may beat too rapidly, too slowly, or irregularly, and your blood pressure may become too high or too low. These changes usually stop within minutes of the injection, but may require treatment with medications or a pacing wire.

The Stress Perfusion Study is optional. However, your physician believes the potential diagnostic benefits for you exceed the risks involved. By signing below you understand the statements above, have had the opportunity to ask questions, and agree to undergo a Stress Perfusion Study as part of your cardiac MRI exam.


X_________________________ (Patient/Legal Guardian)    _____________ (Date)

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