Electrocardiogram (“ECG”) Screening Consent Form and Release of Liability
1. Understanding the ECG Screening
An ECG screening (also known as an EKG) measures the electrical activity of the heart to help identify risks for sudden cardiac death. Screenings performed by Vegas for Athletes (VFA) include an ECG and a medical history form.
2. Consent to Participate and Acknowledgements
By submitting this form, you (or your parent/legal guardian if you are a minor) confirm that you:
- Have read and understood this form and had the opportunity to ask questions
- Voluntarily consent to have VFA representatives and volunteers perform an ECG screening
- Understand and accept all risks associated with the screening
- Acknowledge the screening's limitations — it does not detect all heart conditions or prevent cardiac events
- Understand the screening is not diagnostic and does not replace a physician’s evaluation
- Recognize that abnormal results do not confirm a condition and normal results do not guarantee the absence of a condition
- Accept that technical malfunctions or human error may result in a failed or lost ECG recording, with no liability on VFA
- Understand this screening does not establish a patient-provider relationship, and follow-up is your responsibility
- Confirm you have the authority to sign this Consent and Release
3. ECG Results, Communication, and Confidentiality
A board-certified cardiologist will categorize results as low risk, follow-up required, or higher risk.
- “Higher risk” Participants must undergo further testing before resuming athletics. In some areas, “follow-up required” Participants may also need testing before clearance.
- VFA may share results with those overseeing the Participant’s athletic involvement if further testing is recommended.
- VFA personnel, medical staff, and contractors may access medical records from this screening and contact you regarding results.
- VFA may use anonymized screening data for research or educational purposes. This can be revoked by written notice to VFA.
- VFA will comply with applicable privacy laws, including HIPAA and FERPA
4. Waiver and Release of Claims and Liability
By signing, you waive and release VFA, its affiliates, officers, employees, sponsors, volunteers, and contractors from all claims, damages, or liabilities arising from:
- The performance or results of this screening
- Any undetected conditions, cardiac events, or misinterpretations
- Technical failures, equipment issues, or data loss
- Any claim of personal injury, death, or other loss, even if caused by negligence
This waiver means you give up the right to bring claims for any known or unknown losses related to the screening.
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5. Media Release
You authorize VFA to use photographs, videos, or interviews of you or your child taken during this event for promotional or media purposes, including social media.
6. Acknowledgment of Understanding
You certify that you have read and understand this Consent and Release, or had it explained in a language you understand, and had the opportunity to ask questions about the screening and its risks.