Informed Consent Form - Chemotherapy

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INFORMED CONSENT FORM – CHEMOTHERAPY
PATIENT’S NAME							UID
Gender				Age				WARD / BED NO.
S. N.	DESCRIPTION
1.	I understand that I / my patient, ……………………………………………………………………………….. (name of patient), has been diagnosed with ……………………………………………………… and I have been advised Chemotherapy treatment by my doctor Dr……………………………………………………., I have been explained about the chemotherapeutic agent, process of chemotherapy, expected benefits, risks involved, alternatives available with their risks and consequences of not undertaking Chemotherapy treatment. I give my consent to the hospital and to my doctor to conduct upon me Chemotherapy treatment to the best of their professional ability.
2.	I have been explained the goal of my treatment as …………………………………………………….. I know that whether the goal is achieved or not cannot be guaranteed I understand that Chemotherapy medications can have short term and long term effects. Side-effects that are likely to happen to me are (not limited) (Strike out not applicable one, and add any other) Nausea, Vomiting, Hair Loss, Anemia, Fatigue, Risk of infection, Risk of bleeding, Constipation, Diarrhea, Sores of mouth and throat, Skin effects, muscle effects, bone effects, nerve effects, kidney bladder effects, heart effects, Lung effects, reproductive effects. Other side effects ……………………………………………………………………………………………………… I also understand that complications from chemotherapy can cause my death
3.	Following reasonable alternative to chemotherapy has been explained to me ……………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………
4.	Following consequences has been explained to me, if I do not take chemotherapy ……………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………
5.	I understand that I can withdraw my consent at any point of time, without any prejudice to my treatment. I have had sufficient opportunity to ask questions and clarify my concerns
Signature and name of the person giving consent								Date / Time
Relationship with the patient
Signature and name of the witness								Date / Time
Signature and name of the doctor taking consent								Date / Time

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