Oncology Care Agreement and Treatment Contract

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Agreement Purpose

This agreement between [Practice Name] and the patient establishes mutual understanding and responsibilities for cancer treatment.

Provider Responsibilities

• Develop and discuss comprehensive treatment plans
• Provide evidence-based cancer care following current guidelines
• Monitor treatment response and adjust plans as needed
• Maintain confidentiality per HIPAA regulations
• Coordinate care with other specialists
• Provide emergency contact information
• Explain potential side effects and complications

Patient Responsibilities

1. Attendance and Communication

   • Attend all scheduled appointments
   • Provide 24-hour notice for cancellations
   • Report side effects or complications promptly
   • Update contact information

2. Treatment Compliance

   • Follow prescribed treatment regimens
   • Take medications as directed
   • Complete recommended tests and procedures
   • Maintain accurate medication lists

3. Safety Protocols

   • Inform providers of all medications and supplements
   • Report all side effects and symptoms
   • Follow infection prevention guidelines
   • Adhere to dietary restrictions when applicable

Medication Management

• Prescriptions will be provided only during office hours
• Lost/stolen medication documentation required
• Early refills require documentation and approval
• Random drug screening may be required

Termination Conditions

• Non-compliance with treatment plan
• Missed appointments without notice
• Inappropriate behavior toward staff
• Misuse of prescribed medications

Signatures

Patient: _________________________ Date: _____________ Provider: ________________________ Date: _____________ Witness: _________________________ Date: _____________

Emergency Contact Information

Office Hours: [Phone] After Hours: [Phone] Emergency: 911