Saving Hearts - Screening Registration

Pre-Registration

Horace Mann Community School | April 29th, 2023
Saving Hearts Foundation’s heart screenings are available to any child ages 12-35 for free!

This screen is NOT intended for children who have a diagnosed heart condition and are followed by a cardiologist. The screen is intended to identify an undiagnosed heart disease and should NOT be a substitute for a cardiology visit or follow-up testing. Information relayed during our heart screenings are intended for recommendation purposes only and NOT as formal diagnoses. We encourage any participants to follow up with their own primary care physician or cardiologist to further discuss their findings.
¡Los exámenes cardíacos de Saving Hearts Foundation están disponibles para cualquier niño de 12 a 35 años de forma gratuita!

Esta prueba de detección no está destinada a niños a los que se les haya diagnosticado una afección cardíaca y que sean seguidos por un cardiólogo. La prueba está destinada a identificar una enfermedad cardíaca no diagnosticada y no debe sustituir una visita de cardiología o una prueba de seguimiento.
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Heart Screening Consent Form
Please indicate here if you consent to providing your signature digitally.*

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Heart Screening General Information
Screening Criteria:

Saving Hearts Foundation’s heart screenings are available for any children, young adults, and adults ages 12 to 35. On the day of the screening, participants MUST BE AT LEAST 12 years old and no older than 35 years old.

This screening is NOT intended for children who have a diagnosed heart condition and are being followed by a cardiologist. Our heart screenings are intended to identify an undiagnosed heart disease and should NOT be a substitute for a cardiology visit or follow-up testing.

Information relayed during our heart screenings are intended for recommendation purposes only and NOT as formal diagnoses. At the present time, we encourage any participants to follow up with their own primary care physician or cardiologist to further discuss their findings.

This Screening does NOT replace a Pre-Participation Physical (PPE):

Saving Hearts Foundation’s heart screenings serve to provide a specific evaluation of the heart that is not included in routine PPEs required for most sports programs. It does NOT, however, serve as a replacement for a comprehensive PPE and does not, by itself, fulfill the requirement for a PPE. Saving Hearts Foundation does NOT sign PPE forms. We kindly ask that you please complete your PPE form with your primary care provider or school-appointed physician resource.

Safety Guidelines:

By signing this registration form ahead of your heart screening, you and/or your child are agreeing to adhere to current health and safety guidelines, particularly with regard to COVID-19. For the purposes of social distancing and respecting each participant’s space during their appointment, only ONE parent or guardian will be allowed to accompany the participant through the screening process.

Privacy:

All female participants will be screened by other female volunteers in an area separate from male participants. We want to assure you that participants’ confidentiality, privacy and individual modesty will be respected throughout all aspects of the program. A private screening space is available upon request.

Dress Code:

On the day of the screening, participants should wear a T-Shirt and sweatpants or sport shorts. Girls should wear a sports bra. Girls will be asked to remove the t-shirt but will keep the sports bra on at all times. Any metal jewelry or accessories (i.e., belts) will be asked to be removed in order to collect accurate EKG data.

Heart Screening Process:

Saving Hearts Foundation’s heart screenings are completely painless and non-invasive (no needles or x-ray exposure). Screenings consist of several features:
1. Check In and Registration
2. Blood Pressure and Heart Rate measurements (“Vitals”)
3. Electrocardiogram (ECG or EKG) assessment
4. Echocardiogram (heart ultrasound), if indicated by our cardiologists
5. Cardiologist consultation
6. [Optional] CPR/AED training
7. Check Out
If you or your child has an allergy to latex or any other synthetic materials that may be commonly found in medical devices or equipment, please let us know!

Screening Results:

During your Saving Hearts Foundation heart screening, you will consult with a cardiologist about your cardiac risk assessment and screening results. You will also be advised of any follow-up that may be needed with your medical provider. If you do not have a medical provider, organizations like 2-1-1 Los Angeles can be able to help connect you to health services.

A 12-lead EKG, which is what our foundation uses, is able to identify roughly two-thirds of heart abnormalities associated with sudden cardiac arrest (SCA). Furthermore, our EKGs report approximately a 2% false positive rate that may be discovered during follow up testing. Saving Hearts Foundation and our team of dedicated volunteers make every effort to insure quality outcomes for patients during our heart screenings.

Before leaving our heart screening, you can request a copy of your EKG report. If you leave the screening without a copy of your EKG and wish to obtain a copy for your records, please reach out to records@savingheartsfoundation.com.

This screening does not substitute for a regular on-going relationship with a primary care physician, who is attuned to your medical history and any changes in health status. No screening can identify 100% of the individuals at risk for a sudden cardiac event. As a reiteration, information relayed during our heart screenings are intended for recommendation purposes only and NOT as formal diagnoses. We encourage any participants to follow up with their own primary care physician or cardiologist to further discuss their findings.

We encourage you to continue to have yearly physicals and to contact your medical provider with any concerns or changes in your health, particularly the warning signs and risk factors you’ve commented on in the cardiac risk assessment questionnaire.

The undersigned represent that they have carefully read and fully understand each and every term, condition, and paragraph of the provisions contained in this document.
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Heart Screening Permission Form and Waiver

Digital Signature
I, the undersigned, GIVE permission for my child (under 18 years old)/myself to voluntarily participate in the Saving Hearts Foundation (the Foundation) heart screening (Heart Screening). A cardiac risk assessment questionnaire will be reviewed, an electrocardiogram will be done and an echocardiogram may be performed at the Heart Screening. The heart screening will be conducted by independent health care personnel and other volunteers working together with the Foundation. The undersigned acknowledges and agrees that participation in the Heart Screening is completely voluntary and that it is the undersigned’s decision to have my child/myself participate in this Heart Screening.

The information provided on the accompanying forms is, to the best of my knowledge, complete and correct. I understand and acknowledge that a finding of low risk from the limited screening being performed is not a guarantee of good health. Participation in this program cannot substitute for a consultation with a physician or other medical professional for any medical or health related condition or for regular physical examinations.

I understand and acknowledge that information received from this screening is to be considered preliminary only and does NOT constitute a diagnosis of my child’s/myself health or physical condition. This is NOT a diagnostic study and is NOT intended to replace regular check ups with my child’s/my physician. I further understand and acknowledge that I or another parent/guardian should discuss any abnormal results with my child’s/my personal physician as soon as possible. I or another parent/guardian should ensure that any abnormal results from the Heart Screening are confirmed by a personal physician before any diagnosis or treatment is considered.

In order to have the Heart Screening performed on my child/myself and to participate in a screening, the undersigned, HEREBY RELEASES AND WAIVES ALL CLAIMS, ACTIONS, AND CAUSES OF ACTION that I or my child may otherwise have against the Saving Hearts Foundation, the independent health care personnel and volunteers who are conducting or participating in this screening process, as well as and any vendors, sponsors, their officers, directors, employees, agents, volunteers, and representatives, from any claims, liability, or damages, including but not limited to personal injury or illness arising out of any physical, emotional, or mental injury or death that may occur in any way from my child/myself participation in this program resulting from the negligence, breach of warranty, or strict liability of any persons associated with the Heart Screening. The undersigned further agrees that neither the undersigned nor any of the undersigned’s heirs, personal or legal representatives of family members will bring suit or make a claim for illness, injury, or death resulting from the Heart Screening and that this release is binding upon my heirs, legatees, administrators and personal representatives.

I hereby give my permission for images of my child and/or myself, captured during a youth heart screening through video, photo or digital camera, to be used solely for the purposes of Saving Hearts Foundation's promotional material and publications and waive any rights of compensation or ownership thereto.

I understand that all of the medical information obtained through my child’s/my participation in this program will be kept confidential and will not be retained or used by the screening facility. Once the results of the Heart Screening have been disclosed to the participant, and/or the parent(s), all of the medical information obtained will be de-identified via the removal of personally identifiable information. I give consent that the remaining anonymized data can be collected by the Saving Hearts Foundation or its designees and that it may be used for medical and/or academic research purposes.

I acknowledge that I have read the above agreement to participate and understand its contents. Any questions have been answered to my satisfaction. I agree to be a participant in this heart screening, and in connection therewith, I consent to the release of information obtained in connection with the screening as described above. I understand that Saving Hearts Foundation will not disclose my identity to any third party without my consent. I understand that I may withdraw from the screening.
Contrato para participar en prueba coronaria

Saving Hearts Foundation esta ofreciendo exámenes coronarias para estudiantes, atletas y jóvenes entre 12 y 24 años de edad. La información obtenida de parte de los participantes será revisada por personal medico. La identidad e información de los participantes será confidencial y solo será accesible para los médicos que asistan al evento y por Saving Hearts Foundation. La evaluación puede incluir:
1. Historial medico
2. Revisión de presión
3. Examen físico
4. Electrocardiograma (ECG- registra actividad eléctrica del corazón)
5. Ecocardiograma (imagen ultrasonido del corazón)
Reunión, análisis y evaluación de datos

La reunión de datos de su evaluación será revisada por los médicos asistiendo al evento puede que se utilicen en forma acumulada, sin nombre, como parte de un estudio coronaria para jóvenes. En participar en la evaluación usted esta de acuerdo con el hecho que la información reunida del cuestionario y de la evaluación será evaluada por médicos y puede ser incluida en un estudio medico. Personal medico proveerá un resumen con los resultados de la prueba y puede recomendar un seguimiento adicional con su medico o especialista.

Al participar en este programa le da la autorización a Saving Hearts Foundation y al personal medico para compartir sus resultados con su medico o cardiólogo. Inclusivo da la autorización para que su medico comparta los resultados de cualquier análisis de seguimiento con Saving Hearts Foundation.

Doy consentimiento a Saving Hearts Foundation y al personal medico para usar las imágenes de mí y/o hijo(a) obtenidas durante un momento de grabación de la prueba coronaria a través de video, fotografías o cámara digital, exclusivamente para material promocional y publicaciones de Saving Hearts Foundation. Debido a esto, renuncio a cualquier derecho de propiedad o de compensación.

Acepto que he leído el contrato citado, entiendo su contenido y que mis preguntas han sido contestadas satisfactoriamente. Acepto participar en esta evaluación y por ello doy mi consentimiento para la revelación de la información obtenida a través de la evaluación. Entiendo que Saving Hearts Foundation no divulgara datos personales a terceros sin mi consentimiento. Entiendo que puedo retirarme de la evaluación. Adicionalmente, autorizo que Saving Hearts Foundation, todos los médicos, técnicos, voluntarios, y todas otras personas, entidades, individuos y organizaciones no sean dañados y declino todos derechos de subrogación contra de la prueba coronaria gratuita realizada el día de hoy.
Consent for Future Communication*

Yes. Saving Hearts Foundation may contact me to discuss the information obtained as a result of today's Cardiac Screening.No. I do not want to be contacted in the future about the information obtained as a result of today’s Cardiac Screening.
The undersigned represent that they have carefully read and fully understand each and every term, condition, and paragraph of the provisions contained in this document.
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Parental/Guardian Consent for Participants under the Age of 18:

As parent/guardian of the above minor participant, I acknowledge that I have read the above agreement to participate and understand its contents. Any questions have been answered to my satisfaction. I grant permission for my child to participate in this cardiovascular screening. I consent to the release of information in connection with the screening as described above. I understand Saving Hearts Foundation will not disclose my child's identity to any third party without my consent. I understand that I may withdraw my child from the screening or follow-up at any time without penalty.
Consentimiento de padre/tutor para participantes menores de 18 años:

Como padre/tutor del participante de menor de edad mencionado anteriormente, acepto que he leído el contrato citado y entiendo su contenido y que mis preguntas han sido contestadas satisfactoriamente. Autorizo a que mi hijo(a) participe en esta prueba coronaria. Doy consentimiento para la divulgación de la información relacionada con la evaluación citado. Entiendo que Saving Hearts Foundation no divulgara datos personales se mi hijo(a) a terceros sin mi consentimiento. Entiendo que puedo retirar a mi hijo(a) de la evaluación o seguimiento en cualquier momento sin penalizaciones.
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Consent Obtained via Phone

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Heart Screening Consent Form

Paper Form
Since you have declined to give your consent electronically, please download this PDF form, complete it, and bring it with you on the day of the screening. A link will also be sent along with your confirmation email if you would like to download the form at a later time.

Download Screening Consent Form
Dado que se ha negado a dar su consentimiento de forma electrónica, descargue este formulario en PDF, complételo y tráigalo el día de la proyección. También se enviará un enlace junto con su correo electrónico de confirmación si desea descargar el formulario más adelante.

Descargar formulario de consentimiento de detección

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