Breast Cancer ChoicesTM
Scrutinizing the evidence for breast
cancer procedures and treatments
Chemotherapy Consent Form

    I understand that State law guarantees my right to receive information
    I hereby authorize Dr. __________ and his/her associates to treat my
    ____________.  I understand they will plan and administer cancer
    treatment medication(s), which are intended to control my disease, by
    destroying abnormal cells, reducing the risk of lesion growth or re-
    growth, and preventing or relieving symptoms which may be caused
    by the disease.  These medications may include some of the following:

    I authorize my oncology physicians and their associates to carry out
    the procedures necessary to give me cancer treatment, including, but
    not limited to:  laboratory tests, diagnostic X-ray exams, tissue
    biopsies, and gathering and recording medical information about me.

    This cancer treatment may require the need to have an intravenous
    (IV) line inserted into my body.  This could be with a short-term type of
    IV placed by a nurse, or a longer-term type of catheter, placed by a
    physician.  In addition, this treatment may require the administration of
    medication to minimize side effects such as allergic reactions or
    nausea and vomiting.

    Patients receiving this treatment frequently experience side effects
    which may include, but are not limited to: nausea, vomiting, diarrhea,
    allergic reactions, hair loss, mouth sores, fatigue, numbness and
    tingling of toes and fingers, and bone marrow suppression with the
    risk of infection, anemia, and bleeding,

    For several weeks after the course of treatment I may be very tired;  
    full recovery from cancer medication treatments may require several

    In addition to the short term side effects of treatments, there is a risk
    of major complications, which may be be permanent or may require
    medical or surgical treatments, including but not limited to: organ
    damage, tissue injury secondary to leakage of chemotherapy under
    the skin and infertility,

    There is a small risk that the chemotherapy treatment could cause a
    new cancer or could result in permanent disability or death.

    I have been informed of the benefits and anticipated outcomes of this
    proposed treatment as well as anticipated problems that may occur
    related to recuperation from this treatment. I have also been informed
    of the benefits, risks, and consequences of alternative forms of
    treatment, as well as the likely results if I choose not to be treated.

    I recognize that during the course of my evaluation and treatment,
    unexplained conditions may be discovered, which may require
    additional or different procedures than those mentioned above.  I
    therefore authorize my oncology physician or nurse practitioner to
    evaluate and treat me in accordance with their best professional

    I understand that cancer treatment medication may be harmful to
    human eggs or sperm and to the developing embryo or fetus.  I certify
    that I am not pregnant now and will avoid becoming pregnant or
    fathering children during my treatment and for six month afterward.  If
    there is any chance that I may be pregnant or become pregnant, I will
    tell my oncology physician or nurse practitioner immediately.

    I recognize that there can be no guarantee of benefit or cure from the
    treatment and no assurance that side effects or complications of
    treatment will not occur.  I freely consent to this treatment, knowing
    that I have the right to ask additional questions, refuse or withdraw
    from treatment at any time without affecting my access to care.

    I acknowledge that my physician or nurse practitioner and I have
    discussed the information set forth above and that my questions have
    been answered to my satisfaction.

    By signing below I also certify that this form has been fully explained
    to me, that I have read it or have had it read to me, that the blanks
    have been filled in, that I understand its contents, and that I have
    received a copy. I make this request for treatment and grant the
    authority set forth above voluntarily, and assume responsibility for my

    _____________________                        _____________________________
    Date                                             Signature of Patient or Legal

    ______________________                     ______________________________
    Physician/Nurse                                           Witness
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