Generic Chemotherapy Consent Form

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

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

months.

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

judgment.

I understand that cancer treatment medication may be harmful

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

decision.

_____________________

_____________________________

Date Signature of Patient or Legal

Guardian

______________________

______________________________

Physician/Nurse Witness

Practitioner

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