Oncology Treatment Informed Consent Form

Patient Information

• Full Name: ________________________
• Date of Birth: //____
• Medical Record Number: ____________

Diagnosis and Treatment Plan

I, the undersigned, acknowledge that Dr. _________________ has diagnosed me with: _________________________ (type and stage of cancer)

The following treatment plan has been proposed:

• Chemotherapy
• Radiation therapy
• Immunotherapy
• Targeted therapy
• Surgery
• Other: ________________

Understanding of Treatment

I confirm that I have been informed about:

1. The nature and purpose of the proposed treatment
2. Potential benefits and likelihood of success
3. Alternative treatment options
4. Significant risks and side effects
5. Expected recovery process

Common Side Effects

• Nausea and vomiting
• Fatigue
• Hair loss
• Decreased blood counts
• Increased risk of infection
• ________________________ (additional specific to treatment)

Serious Risks

I understand that serious complications may occur, including but not limited to:

• Severe allergic reactions
• Organ damage
• Secondary cancers
• Life-threatening infections
• ________________________ (treatment-specific risks)

Patient Acknowledgment

I confirm that:

• All my questions have been answered satisfactorily
• I have had sufficient time to consider this decision
• I understand I may withdraw consent at any time
• I have disclosed all relevant medical information

Signatures

Patient Signature: _________________ Date: //____ Physician Signature: ______________ Date: //____ Witness Signature: ________________ Date: //____

Emergency Contact

Name: ________________________ Relationship: __________________ Phone: ________________________