Patient Registration and Consent Form

Which clinic are you attending?*

Sydney - ChatswoodBrisbane - Herston

First Name*

Surname*

Date of Birth*

Sex*

MaleFemale

Mobile Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have a Medicare Card?*

YesNo - I am not an Australian Citizen or Permanent Resident

Medicare Card Number

Medicare Card Line Number (Which Number are you on the card?)

Are you able to walk on a treadmill for at least 6 minutes at a normal walking pace?*

YesNo

Package: HeartCheck Assessment – Includes medical history review, physical examination, screening blood tests, treadmill Exercise Stress Test (ECG), and CT Calcium Score.

I, {firstName} {surname}, consent to undergo the components of the HeartCheck Assessment as listed above.

I understand and acknowledge the following:

Nature and Purpose
The HeartCheck Assessment is a preventive cardiac screening service designed to assess risk factors and detect possible signs of heart disease. It is not a specialist cardiology service and does not replace ongoing care from my general practitioner or cardiologist.

Exercise Stress Test
I consent to the treadmill Exercise Stress Test (ECG), which involves gradual walking/jogging with increasing speed and incline while my heart is monitored.

I may experience fatigue, shortness of breath, muscle ache, or chest discomfort, and I can stop the test at any time.
Rare risks (<1 in 1,000) include abnormal heart rhythms, heart attack, or collapse. Emergency equipment and trained staff are present.
The test may be stopped early if concerning signs appear.
I will be continuously monitored with emergency equipment immediately available.

Limitations of a Normal Result

Even if my HeartCheck Assessment results are normal (a “clean bill of health”), there remains a small possibility that coronary artery disease or other cardiac conditions may still be present. A normal result significantly reduces but does not completely eliminate risk.
I understand I must always treat new or worsening symptoms seriously (such as chest pain, shortness of breath, dizziness, or palpitations) and seek immediate medical attention (call 000 or see my GP/cardiologist).

CT Calcium Score
This low-radiation CT scan detects calcified plaque. Minimal risk (radiation equivalent to ~1 year background). Performed at partner radiology.

Blood Tests
Blood collection involves minimal risk (bruising, faintness).

Further Investigations and Referrals
Heartcheck Australia is not a specialist cardiology service. Results are reviewed in consultation with cardiologists where required.
If the assessment reveals any abnormalities we believe need specialist follow-up, we will refer you to a cardiologist (ours or your preferred one).
All fees for specialist cardiologist consultations, further testing, or treatment are payable by me and are not included in the fees paid to Heartcheck Australia.

Privacy
My information will be handled in accordance with Heartcheck Australia’s Privacy Policy and the Privacy Act 1988 (Cth).

Voluntary Participation
I participate voluntarily and may withdraw at any time.

I confirm that I have been given the opportunity to ask questions about the HeartCheck Assessment, its components, benefits, risks, and limitations — whether by phone, email, or through information provided on the Heartcheck Australia website.
I am satisfied with the information I have received and have no further questions at this time.

Sender Name

Sender Email

Signature*

Date*

Date

Hour MinutesAM/PM Option

Please verify that you are human*

Patient Registration and Consent Form

Consent for HeartCheck Assessment