Cancer Services
1. Please change macro security to
RADIOTHERAPY
CONSENT
FORM
medium. By referring
to the images
below:
PATIENT DETAILS
Forenames:
Surname:
Hospital Number:
Date of Birth:
Consultant:
Age:
Sex
Special Requirements
None
e.g. transport, interpreter
DETAILS OF COURSE OF TREATMENT
(including brief explanation if medical terms not clear)
Radiotherapy
Treatment*:
Treatment*:
Site*:
STATEMENT OF HEALTH PROFESSIONAL
(to be filled in by health professional with appropriate knowledge of proposed procedure)
I have explained the proposed treatment to the patient. In particular, I have explained: N/A
Treatment Intent*:
Adjuvant:
Chemotherapy:
Definitions:
SERIOUS, UNAVOIDABLE OR FREQUENTLY OCCURRING SIDE-EFFECTS
(to be filled in by health professional with appropriate knowledge of proposed procedure)
This treatment may cause side-effects as follows:
None
Note: This list of side-effects is not exhaustive. Many side effects are temporary, with the exception of hair loss, and
usually improve within 4-6 weeks after stopping treatment. Irradiated skin may remain darker, or occasionally lighter
with visible small blood vessels long term.
Radiotherapy can damage the testis or ovary, leading to increase risk of infertility and early menopause. I have
warned the patient about the likelihood of:
Early menopause and infertility
Infertility
2. Reopen the file and enable macros
as shown below.
Any other risks:
LONG TERM RISKS
(to be filled in by health professional with appropriate knowledge of proposed procedure)
This treatment may cause:
None
Any other risks:
ANY EXTRA PROCEDURES WHICH MAY BECOME NECESSARY:
(to be filled in by health professional with appropriate knowledge of proposed procedure)
None
ISSUE 1
Radiotherapy (
,
)
3. For assistance
please contact Simon
To be retained in the patient’s records
Hack at simon.hack@uclh.nhs.uk
APRIL 2013
Page 1 of 3
Cancer Services
STATEMENT OF HEALTH PROFESSIONAL
(to be filled in by health professional with appropriate knowledge of proposed procedure)
I have also discussed what the treatment is likely to involve, the benefits and risks of any available alternative
treatments (including no treatment) and any particular concerns of this patient. All relevent patient information
leaflets, books or tapes have been provided.
Patient Information provided:
Signature:
Date:
Name:
Job Title:
CONTACT DETAILS (if patient wishes to discuss options later)
Name:
Job Title:
Phone:
Bleep:
STATEMENT OF INTERPRETER (where appropriate
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can
understand.
Signature:
Date:
Name:
Job Title:
STATEMENT OF PARENT/CARER
Please read this form carefully. If you have any further questions, do ask – we are here to help you and your child.
You have the right to change your mind at any time, including after you have signed this form.
I agree to the course of treatment described on this form and I confirm that I have 'parental responsibility' for this child
I understand that my child and I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before
the procedure, unless the urgency of the situation prevents this. (This only applies to patients having general or regional
anaesthesia.)
I understand that further medical treatments may be required to treat side-effects of radiotherapy.
I have been told about additional procedures which may become necessary during my child's treatment. I have listed
below any procedures which I do not wish to be carried out without further discussion:
Signature:
Date:
Name:
ISSUE 1
Radiotherapy (
To be retained in the patient’s records
,
)
APRIL 2013
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Cancer Services
STATEMENT OF WITNESS/PARENT (where appropriate)
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children
may also like a parent to sign here (see notes).
Signature:
Date:
Name:
IMPORTANT NOTES (where appropriate)
See also advance directive/living will (e.g. Jehovah’s Witness form)
Patient has withdrawn consent (ask patient to sign /date here)
ISSUE 1
Radiotherapy (
_____________________ Date:
To be retained in the patient’s records
,
)
/
/
APRIL 2013
Page 3 of 3