Consent for Chemotherapy Biologic Therapy

AFFIX PATIENT INFO LABEL HEREPatient Name ________________________ MR# ___________Consent for Chemotherapy/Biologic TherapyPATIENT _____________________, I hereby authorize Dr.physician designates, to prescribe the following treatment:, or whomever theTREATMENT:1. I have received a detailed explanation of the treatment to be given. I understand that I will be given this treatment inan effort to produce better control or remission of my disease. I feel the potential benefits of the therapy outweigh thepossible side effects and risks.2. I have received a description of all the known side effects, discomfort, and risks that may reasonably be expectedwhen receiving this treatment.Chemotherapy:Chemotherapy consists of medications, which are used to destroy fast growing cancer cells in the body. These drugscannot tell the difference between fast growing cancer cells or healthy cells, so damage occurs to both. This causesside effects such as: hair loss, nausea and vomiting, mouth sores or mouth ulcers, risk of infection, risk of bleeding,and possibly others as are listed on the specific drug information sheets included.Biologic Therapy:Biologic therapy consists of medications which are used as treatment to stimulate or restore the ability of the immunesystem to fight cancer.3. Alternative forms of therapy, drugs and treatments, along with the possible advantages or disadvantages have beenexplained to me.4. I understand that during the course of the treatment(s), an unforeseen condition may become apparent, which mayrequire an extension or modification of the original treatment plan described above. If such condition is an emergentmatter and must be treated immediately, I authorize that such treatment(s) may also be performed. Otherwise,I expect that any extension or modification of the original treatment plan be fully explained to me before beingrendered.5. I understand that the drugs that I may be receiving as part of my treatment may have the potential to cause allergicreactions or anaphylaxis, which could put me at risk of respiratory distress or other untoward reactions. I understandthat these potential risks are related to the drugs, not my underlying disease, and should be reversible withimmediate interventions, including cardiopulmonary resuscitation and/or intubation, and I consent to theseinterventions if needed.6. The nature and purpose of the above treatment(s), as well as its possible side effects, consequences, alternativesand risks, have been reasonably explained, and no guarantee or assurance has been made to the results whichmay be obtained, it being recognized that medicine is not an exact science.7. I acknowledge that I have read and agree to the foregoing, that the proposed treatment has been satisfactorilyexplained to me and that I have been given sufficient opportunity to ask questions about my condition and treatmentand I have sufficient information to give this consent. I understand that I am able to withdraw my consent and stoptreatment at any time.Consent for Chemotherapy/Biologic Therapy Medical Record HUMC NS# 5059529 Rev. 4/21/09 Page 1 of 2

AFFIX PATIENT INFO LABEL HEREPatient Name ________________________ MR# ___________Date:Patient:Parent/Guardian/Other:Date:Witness:Practitioner:Relationship:Reason patient is unable to sign:THIS SECTION IS TO BE COMPLETED ONLY FOR PATIENTS WHO HAVE A CURRENTDO NOT RESUSCITATE (DNR)ORDER ON THE CHARTPatients with DNR/DNI orders: I understand that, while I am receiving chemotherapy or biologic therapy atThe Cancer Center, my do-not-resuscitate (DNR) and/or do-not-intubate (DNI) order will be suspended duringthe time any drugs are being infused and for 30 minutes after the infusion has ended to permit me to receivethe necessary treatment in the event of a drug reaction described above.Date:Patient:Parent/Guardian/Other:Date:Witness:Practitioner:Relationship:Reason patient is unable to sign:Consent for Chemotherapy/Biologic Therapy Medical Record HUMC NS# 5059529 Rev. 4/21/09 Page 2 of 2