Oncology Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: _____________________

1. Treatment Plan Overview

I, _________________________, understand that I have been diagnosed with ___________________________ and agree to receive cancer treatment at [Practice Name].

2. Consent for Treatment

• I authorize Dr. _________________ and associates to administer chemotherapy, immunotherapy, and/or targeted therapy as discussed
• I understand that my treatment plan includes: [specify treatments]
  • Chemotherapy agents: ____________________
  • Frequency of administration: ______________
  • Duration of treatment: ___________________

3. Understanding of Risks and Benefits

I acknowledge that I have been informed of:

• The purpose of the recommended treatment
• Potential side effects and complications
• Alternative treatment options
• Expected outcomes and prognosis
• The right to refuse treatment at any time

4. Patient Responsibilities

I agree to:

• Attend all scheduled appointments
• Report any side effects or concerns promptly
• Inform the medical team of any new medications
• Follow medication and care instructions
• Maintain current contact information

5. Financial Understanding

• I understand my insurance coverage and financial responsibilities
• I have discussed payment arrangements with the billing department

6. Emergency Procedures

In case of severe side effects or emergencies:

• Contact the oncology office at: _________________
• After hours number: __________________________
• Go to nearest emergency department if instructed

Signatures

Patient: _________________________ Date: ____________

Physician: _______________________ Date: ____________

Witness: _________________________ Date: ____________