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Babu N. Jasty, M.D., P.b.
Buddhadev N. Manvar, M.D., P.b.
Diplomates Internal Medicine
and Cardiovascular Diseases

240 Willoughby Street, Suite 10F
Brooklyn, NY 11201
(718) 783-7001
9413 Flatlands Avenue
Brooklyn, NY 11236
(718) 257-4800
6414 Bay Parkway
Brooklyn, NY 11204
(718) 234-2300

Informed Consent for Exercise Testing Form

  1. Explanation of the Graded Exercise Test

    You will perform a graded exercise test on a bicycle ergometer and/or a motor-driven treadmill. The work level will begin at a level you can easily accomplish. We may stop the test at any time because of signs of fatigue or discomfort. We do not wish you to exercise at a level which is abnormally uncomfortable for you.

  2. Risks and Discomforts

    There exists a possibility of certain changes occuring during the test. They include abnormal blood pressure, fainting, disorders of heart beat, and very rare instances of heart attack. Every effort will be made to minimize these by the preliminary examination and by observations during testing. Emergency equipment and training personnel are available to deal with unusual situations that may arise.

  3. Benefits to Be Expected

    The results obtained from the exercise test may assist in the evaluation of cardiovascular fitness.

  4. Inquiries

    Any questions about the procedures used in the graded exercise test or in the estimation of functional capacity are welcome. If you have any doubts or questions, please ask for further explanations.

  5. Freedom of Consent

    Permission for you to perform this graded exercise test is voluntary. You are free to deny consent if you so desire.

I have read this form and I understand the test procedures that I will perform. I hereby consent to participate in this test, and I hereby authorize Dr.__________________________ and his associates to perform the exercise on ______________________ (date).

Patient Signature:
Physician Signature:

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