Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM FMD. Patient s first names.
|
|
- Augustine Wheeler
- 6 years ago
- Views:
Transcription
1 Patient identifier/label: Page 1 of 6 Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS number (or other identifier) South London Healthcare NHS Trust: Princess Royal University Hospital Queen Elizabeth Hospital Queen Mary s Hospital Male Female Special requirements (e.g. other language/other communication method) Chemotherapy for Lymphoma FMD Oral Fludarabine / Mitoxantrone / Oral Dexamethasone Responsible health professional Job title Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) FMD chemotherapy: Oral Fludarabine on days 1, 2 and 3 Intravenous Mitoxantrone on day 1 Oral Dexamethasone on days 1 to 5 Every 28 days for up to 6 cycles
2 Patient identifier/label: Page 2 of 6 Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy) I have explained the procedure to the patient. In particular, I have explained: The intended benefits Improved survival Control of symptoms Induction therapy given in the acute state of the disease, aiming to shrink the tumour Curative to give you the best possible chance of being cured Maintenance therapy given on continuing basis, aiming to prevent disease flaring up and to control the symptoms Disease control / Palliative the aim is not to cure but to control the disease and reduce the symptoms. The aim is to improve both quality and quantity of life General risks with this treatment: Significant, unavoidable or frequently occurring: Common side-effects include bruising or bleeding, anaemia (low number of red blood cells), feeling sick (nausea) and being sick (vomiting). This treatment can also cause tiredness, loss of appetite, alter the way food tastes, sore mouth and mouth ulcers. Hair loss is unusual with FMD treatment, but some people may notice hair thinning. There may be increased risk of tumour-lysis syndrome in the presence of high tumour burden (high number of cancer cells present in the body). Precautions will be taken to minimise the risk of complications with preventative supplementary medicines. Less common, but a potentially life threatening side-effect is reduced resistance to infection. It is vital that you contact your doctor or the hospital or if outside of normal working hours the on-call hospital doctor straight away if: your temperature goes above 38ºC (100.4ºF) you suddenly feel unwell (even with a normal temperature). Your doctor or nurse will give you the phone numbers to call should these symptoms occur. These symptoms indicate that you have an infection. It is an emergency and it is very important that you contact the hospital / your doctor.
3 Patient identifier/label: Page 3 of 6 Potential side-effects with the anti-sickness medication may include: constipation, headaches, indigestion, difficulty sleeping and agitation. Some chemotherapy drugs can damage women s ovaries and men s sperm, with risk of infertility and early menopause in women. I have warned the patient about the likelihood of: early menopause in women infertility (in men and in women) Some chemotherapy drugs may damage the development of a baby in the womb (foetus), leading to the many risks associated with an abnormal pregnancy. Therefore, I have discussed the issues of protected sex. This is an issue for both men and women. The patient has been advised not to become pregnant / not to get a partner pregnant during the period of treatment. Specific risks and side effects of the drugs used in this treatment: Fludarabine treatment makes you more prone to developing a chest infection called pneumocystis (PCP). You will be given a preventative antibiotic called cotrimoxazole (Septrin ) during treatment and for a few months after your treatment has finished. Fludarabine depletes a certain type of cell in your blood (T cells) and therefore you will require a special type of blood transfusion (irradiated and CMV negative blood) while you are receiving Fludarabine treatment. Fludarabine will cause reduced immune system function and this can activate underlying viral infections. You will be given preventative anti-viral medication during your treatment to reduce risk of viral infections whilst your immune system is affected. Mitoxantrone may leak in the tissue around the vein while it is being given causing pain around the vein. Mitoxantrone may cause urine, saliva, tears and sweat to turn blue-green for 24 hours post infusion. Whites of eyes may have a blue-green tinge (this is normal). Mitoxantrone may cause changes to the way your heart functions and this may need monitoring during your treatment. Dexamethasone can cause irritation of the stomach lining, increase your appetite and cause changes in the blood sugar levels. Other less common side-effects include fluid retention and changes in behaviour (mood swings, difficulty sleeping, anxiety or irritability).
4 Patient identifier/label: Page 4 of 6 What the treatment is likely to involve (including inpatient / outpatient treatment, timing of the treatment, follow-up appointments etc) and location. Any other risks:... I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. The following leaflet/tape has been provided: Macmillan/Cancerbackup leaflets for Fludarabine and Mitoxantrone chemotherapy 24 hour chemotherapy service contact details.. Signed:. Name (PRINT). Date.... Job title... Contact details (if patient wishes to discuss options later)... Statement of interpreter (where appropriate) Language Line ref: I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand. Signed.. Date... Name (PRINT).. Copy accepted by patient: yes/no (please ring)
5 Patient identifier/label: Page 5 of 6 Statement of patient Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of page 2 which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask we are here to help you. You have the right to change your mind at any time, including after you have signed this form. I agree to the procedure and course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate training and experience. I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health. I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion. Patient s signature.. Date.. Name (PRINT) A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children may also like a parent to sign here (see notes). Signature Date... Name (PRINT). Confirmation of consent (to be completed by a health professional when the patient is admitted for the procedure, if the patient has signed the form in advance) On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions and wishes the procedure to go ahead. Signed:. Name (PRINT). Date.... Job title... Important notes: (tick if applicable) See also advance decision (eg Jehovah s Witness form) Patient has withdrawn consent (ask patient to sign /date here)....
6 Patient identifier/label: Page 6 of 6 Guidance to health professionals (to be read in conjunction with consent policy) What a consent form is for This form documents the patient s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoire to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient. The law on consent See the Department of Health s Reference guide to consent for examination or treatment for a comprehensive summary of the law on consent (also available at Who can give consent Everyone aged 16 or more is presumed to have the capacity to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has sufficient understanding and intelligence to enable him or her to understand fully what is proposed, then he or she will have the capacity to give consent for himself or herself. Young people aged 16 and 17, and legally competent younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for himself or herself, some-one with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child s care, unless the child specifically asks you not to do so. If a patient has the mental capacity to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally. When NOT to use this form If the patient is 18 or over and lacks the capacity to give consent, you should use form 4 (form for adults who lack the capacity to consent to investigation or treatment) instead of this form. A patient lacks capacity if they have an impairment of the mind or brain or disturbance affecting the way their mind or brain works and they cannot: understand information about the decision to be made retain that information in their mind use or weigh that information as part of the decision-making process, or communicate their decision (by talking, using sign language or any other means). You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so. Relatives cannot be asked to sign a form on behalf of an adult who lacks capacity to consent for themselves, unless they have been given the authority to so under a Lasting Power of Attorney or as a court appointed deputy. Information Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about significant risks which would affect the judgement of a reasonable patient. Significant has not been legally defined, but the GMC requires doctors to tell patients about serious or frequently occurring risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on page 2 of the form or in the patient s notes. References: 1- South East London Cancer Network, Agreed lists of Chemotherapy Regimens 2- Macmillan Cancer Support, Cancer Information 3- Royal Marsden NHS Foundation Trust, Consent Forms Risk Table Verbal description a Risk Risk description b Very common 1/1 to 1/10 A person in family Common 1/10 to 1/100 A person in street Uncommon 1/100 to 1/1000 A person in village Rare 1/1000 to 1/ A person in small town Very rare 1/ to 1/ A person in large town a EU-assigned frequency b Unit in which one adverse event would be expected
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 + RITUXIMAB
Patient identifier/label: Page 1 of 6 FORM CHOP 21 + RITUXIMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM DOCETAXEL + PREDNISOLONE. Patient s first names
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM DOCETAXEL + PREDNISOLONE Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CYTARABINE CONTINUOUS INFUSION
Patient identifier/label: Page 1 of 6 CYTARABINE Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM PEGYLATED LIPOSOMAL DOXORUBICIN (CAELYX)
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM PEGYLATED LIPOSOMAL DOXORUBICIN (CAELYX) Patient s surname/family name Patient s first names Date of birth Hospital
More informationPatient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM IMATINIB. Patient s first names.
Patient identifier/label: Page 1 of 5 Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS number
More informationPATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM WEEKLY RITUXIMAB. Patient s first names. Date of birth
Page 1 of 5 FORM WEEKLY RITUXIMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS number
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM VISMODEGIB. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM VISMODEGIB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St.
More informationOral Ibrutinib (single agent)
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM IBRUTINIB Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number (or other
More informationPATIENT AGREEMENT TO SYSTEMIC THERAPY: GENERIC CONSENT FORM. Patient s first names. Date of birth. Job title
Patient identifier/label: Page 1 of 5 GENERIC CONSENT FORM Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number (or other identifier) Male Female Special requirements
More informationPatient identifier/label: Page 1 of 6. Patient s first names. Date of birth
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ENZALUTAMIDE Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St.
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM PAZOPANIB. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM PAZOPANIB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM TRASTUZUMAB (HERCEPTIN) Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM TRASTUZUMAB (HERCEPTIN) Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Gemcitabine-Cisplatin PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Gemcitabine-Doxorubicin PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Lomustine PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Vinorelbine (oral) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM DENOSUMAB. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM DENOSUMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Cetuximab (+/- Chemotherapy) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier)
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Cetuximab (+/- platinum-based chemotherapy) HOSPITAL NAME/STAMP: PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH:
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Lenvatinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
More informationPatient agreement to investigation, treatment or procedure
Appendix A: Consent Form 1 Consent form 1 Patient agreement to investigation, treatment or procedure Patient details (or pre-printed label) Patient s surname/family name... Patient s first names.. Date
More informationPATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Cabozantinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
More informationCONSENT FORM UROLOGICAL SURGERY
CONSENT FORM for UROLOGICAL SURGERY (Designed in compliance with consent form 1) PATIENT AGREEMENT TO INVESTIGATION OR TREATMENT Patient Details or pre-printed label Patient s NHS Number or Hospital number
More informationMethylprednisolone and Cyclophosphamide for lung fibrosis Information for patients
Methylprednisolone and Cyclophosphamide for lung fibrosis Information for patients This leaflet can be made available in other formats including large print, CD and Braille and in languages other than
More informationSentinel node biopsy. Patient Information to be retained by patient
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label Sentinel Node Biopsy What is a sentinel node biopsy? The lymphatic drainage from your
More informationGenerator or box changes for your implantable device
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a generator? The generator (sometimes called the box ) is the battery that
More informationTop copy accepted by patient: yes/no (please ring)
Consent Form 3 Patient / Parental agreement to investigation or treatment Procedures where consciousness not impaired Name of proposed procedure or course of treatment Hospital NHS Surname no: no: OUTPATIENT
More informationCare of Your Peripherally Inserted Central Catheter
Care of Your Peripherally Inserted Central Catheter A guide for patients and their carers Acute Oncology Patient Information Leaflet Contents Information for patients: What is a PICC? How is it put in?
More informationHickman line insertion and caring for your line
Hickman line insertion and caring for your line Information for patients This booklet explains how a Hickman line is put in, the benefits, the risks and the alternatives, as well as how to care for your
More informationTreatment of non-muscle invasive bladder cancer with BCG and EMDA MMC
Treatment of non-muscle invasive bladder cancer with BCG and EMDA MMC This information sheet has been given to you to explain the combined use of BCG and EMDA MMC to treat your non-muscle invasive bladder
More informationDiagnostic Upper Gastrointestinal Endoscopy
Diagnostic Upper Gastrointestinal Endoscopy Endoscopy Department Patient information leaflet This leaflet explains more about having a gastroscopy, including the benefits, risks and any alternatives and
More informationIndividualised End of Life Care Plan for the Last Days or Hours of Life Patient name Hospital number Date of birth
Individualised End of Life Care Plan for the Last Days or Hours of Life Patient name Hospital number Date of birth NHS number Informed by Five Priorities for Care: Recognise, Communicate, Involve, Support,
More informationBowel Screening Wales Information booklet for care homes and associated health professionals. Available in other formats on request. October.14.v.2.
Bowel Screening Wales Information booklet for care homes and associated health professionals Available in other formats on request October.14.v.2.0 Contents Section 1 Page 3 Who are Bowel Screening Wales
More informationPatient copy. Periurethral bulking agent for stress urinary incontinence. Patient Information to be retained by patient
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label Who is this leaflet for? This leaflet provides information about having an injection
More informationAdvance Health Care Planning: Making Your Wishes Known. MC rev0813
Advance Health Care Planning: Making Your Wishes Known MC2107-14rev0813 What s Inside Why Health Care Planning Is Important... 2 What You Can Do... 4 Work through the advance health care planning process...
More informationHaving a blue light cystoscopy
Having a blue light cystoscopy The aim of this information sheet is to help answer some of the questions you may have about having a blue light cystoscopy. It explains the benefits, risks and alternatives
More informationWELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT You are scheduled to have an appointment at the UPMC Liver Cancer Center which is located in the UPMC Montefiore
More informationHealth Care Directive
MINNESOTA PATIENT EDUCATION Health Care Directive Making Your Health Care Choices Known My Health Care Directive My health care directive was created to guide my health care agent and family, friends or
More informationTrans Urethral Resection of Bladder Tumour (TURBT) (Day Case)
Trans Urethral Resection of Bladder Tumour (TURBT) (Day Case) Department of Urology Information for patients i What is a Trans Urethral Resection of Bladder Tumour (TURBT)? Your recent cystoscopy has shown
More informationADVANCE DIRECTIVE FOR HEALTH CARE
ADVANCE DIRECTIVE FOR HEALTH CARE This document includes a list of definitions and the two types of Advance Directives (together called a Combined Directive). Some people choose to fill out only one portion.
More informationCHPCA appreciates and thanks our funding partner GlaxoSmithKline for their unrestricted funding support for Advance Care Planning in Canada.
CHPCA appreciates and thanks our funding partner GlaxoSmithKline for their unrestricted funding support for Advance Care Planning in Canada. For more information about advance care planning, please visit
More informationAbout your PICC line. Information for patients Weston Park Hospital
About your PICC line Information for patients Weston Park Hospital This booklet explains what a PICC line is, how it is inserted and some general advice on its use and care. What is a PICC line? A Peripherally
More informationChildren s Ward Parent/Carer Information Leaflet
Operation to remove tonsils Children s Ward Parent/Carer Information Leaflet Introduction Your child s consultant has suggested that your child has an operation to remove their tonsils. This leaflet explains
More informationConsent for Blood Transfusion
Consent for Blood Transfusion Vicki Davidson Transfusion Practitioner Consent It is a general legal and ethical principal that valid consent should be obtained from a patient (or parent/guardian) before
More informationHealth Care Directive
Health Care Directive Overview Adults with decision-making capacity have the right to make choices about their health care. No treatments may be given to someone who does not want them. The attached Durable
More informationMy Voice - My Choice
My Voice - My Choice My Advance Directive Table of Contents Introduction... 2 Words You Need to Know... 3 Legal Document... 4 Helpful Information about your Advance Directive... 10 What makes your life
More informationLast Name: First Name: Advance Directive including Power of Attorney for Health Care
Patient Medical Record Number: Or Label Advance Directive including Power of Attorney for Health Care Overview This legal document meets the requirements for Wisconsin.* It lets you Name another person
More informationRegulation STUDENTS August 13, Management of Students with Cancer in the School Setting
August 13, 2008 Management of Students with Cancer in the School Setting These are guidelines to follow when the school is informed of the presence of a student with a cancer diagnosis. I. Modern advanced
More information~ Arizona. Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT
~ Arizona ~ Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care may be given to you over
More informationTo Whom It May Concern: Enclosed is the Power of Attorney for Health Care form which you requested.
DIVISION OF PUBLIC HEALTH 1 WEST WILSON STREET P O BOX 2659 Jim Doyle MADISON WI 53701-2659 Governor State of Wisconsin 608-266-1251 Helene Nelson FAX: 608-267-2832 Secretary Department of Health and Family
More informationW e l c o m e t o B i l l e r i c a C h i r o p r a c t i c
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security
More information~ Minnesota. Durable Power of Attorney for Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT
~ Minnesota ~ Durable Power of Attorney for Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. NO HEALTH CARE MAY BE GIVEN
More informationNHS Continuing Health Care Consent Form
NHS Continuing Health Care Consent Form Surname/family name (of individual being assessed) First names Date of birth: NHS number (or other identifier)... Responsible professional 1 Name:...... Job title...
More informationLast Name: First Name: Advance Directive. including Power of Attorney for Health Care
Overview Patient Medical Record Number: Or Label Advance Directive including Power of Attorney for Health Care This legal document meets the requirements for Wisconsin.* It lets you Name another person
More information~ Wisconsin. Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT
~ ~ Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care may be given to you over your objection,
More informationPatient & Family Guide. Blood Transfusion. Aussi disponible en français : La transfusion sanguine (FF )
Patient & Family Guide 2017 Blood Transfusion Aussi disponible en français : La transfusion sanguine (FF85-1811) www.nshealth.ca Blood Transfusion You have been given this pamphlet because you or your
More informationBurton M. Sundin, M.D. / Reps B. Sundin, M.D. Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: address:
Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: Email address: Patient Status: 1-Married 2 Single 3-Separated 4-Divorced 5-Widowed 6-Other Birthdate: Sex: Social Security#:
More informationReceiving a transfusion
Receiving a transfusion A patient s guide 1 Why might a transfusion be needed? Transfusions are sometimes given to replace any blood you lose during or after surgery; this is quite normal. Less than half
More informationINFORMATION FOR PATIENTS
The British Association of Urological Surgeons 35-43 Lincoln s Inn Fields London WC2A 3PE Phone: Fax: Website: E- mail: +44 (0)20 7869 6950 +44 (0)20 7404 5048 www.baus.org.uk admin@baus.org.uk INFORMATION
More informationWhat is TB? Prevention is better than cure. You can get latent or active TB even if you have had a BCG vaccination
What is TB? Tuberculosis (TB) is an illness caused by bacteria. When someone with TB in their lungs coughs or sneezes, they send TB bacteria into the air. If you breathe in these bacteria, one of three
More informationCovert Administration of Medicines Policy and Procedure
1 Final Draft 1. Policy Covert Administration of Medicines Policy and Procedure 1.1 Why? The Nursing and Midwifery Council has recognised there will be instances where it is appropriate to administer medication
More informationWirral Community NHS Trust Consent Form 4
Wirral Community NHS Trust Consent Form 4 Form for adults who are unable to Consent to investigation or treatment Patient details (or pre-printed label) Patient's surname/family name Patients first names
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust
The Newcastle upon Tyne Hospitals NHS Foundation Trust Advance Decision to Refuse Treatment Policy (Advanced Refusal of Treatment/ Previously known as Living Wills) Incorporating the Mental Capacity Act
More information~ Colorado. Medical Durable Power of Attorney for Healthcare Decisions Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT
~ Colorado ~ Medical Durable Power of Attorney for Healthcare Decisions Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care
More informationALLINA HOME & COMMUNITY SERVICES ALLINA HEALTH. Advance Care Planning. Discussion guide. Discussion Guide. Advance care planning
ALLINA HOME & COMMUNITY SERVICES ALLINA HEALTH Advance Care Planning Discussion guide Discussion Guide Advance care planning Advance care planning Any of us could think of a time when we might be too sick
More information~ Wisconsin. Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT
~ Wisconsin ~ Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care may be given to you over
More information~ Rhode Island ~ Durable Power of Attorney For Health Care Christian Version
~ Rhode Island ~ Durable Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care may be given
More informationInformation for patients having Prophylactic Cranial Irradiation (PCI): precautionary radiotherapy to the brain
Information for patients having Prophylactic Cranial Irradiation (PCI): precautionary radiotherapy to the brain Introduction This leaflet is for people who have been recommended treatment with a short
More informationHaving a Vena Cava Filter
Having a Vena Cava Filter Department of Radiology Information for Patients i Radiology Leaflet No. 30 Contents Page number Introduction 3 Referral and consent 3 Why do I need a vena cava filter inserted?
More informationCyclophosphamide INFUSION Infusion 4 Plus
Cyclophosphamide Infusion Day DEPARTMENT OF RHEUMATOLOGY DAY CASE ADMISSION RECORD PATIENT DAY CASE BOOKING REQUEST To be completed by Consultant, Registrar requesting day case Admission Hospital No. Forename
More informationEtoposide (VePesid ) ( e-toe-poe-side )
Etoposide (VePesid ) ( e-toe-poe-side ) How drug is given: by mouth Purpose: to stop the growth of cancer cells in ovarian cancer, small cell lung cancer, Hodgkin disease, and other cancers How to take
More informationNew Patient Registration Form NJR_NP_F100
New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient
More informationInstruction Sheet for Completing Health Care Power of Attorney/Living Will (Please discard instruction sheet after completion of document)
Instruction Sheet for Completing Health Care Power of Attorney/Living Will (Please discard instruction sheet after completion of document) Overview The attached Power of Attorney for Health Care form is
More informationInfliximab Infusion for Patients with Ulcerative Colitis Patient Information Leaflet
Infliximab Infusion for Patients with Ulcerative Colitis Patient Information Leaflet Originator: Lindsey Wood Date: March 2011 Version: 2 Date for Review: March 2014 DGOH Ref No: DGOH/PIL/00304 Contact
More informationSMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)
SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) Name: Former/ Maiden Name: Date of Birth: Age: Today s Date: *Language: Race: Ethnicity: *Do
More informationCONSENT FOR SURGERY OR SPECIAL PROCEDURES
Admission Date THE VALLEY HOSPITAL CONSENT FOR SURGERY OR SPECIAL PROCEDURES - Colonoscopy 1. Authorization. I hereby authorize Dr. (" my Doctor") and any such assistants or designees as may be selected
More informationAbdominal Pain Advice for Parents/Carers
Abdominal Pain Advice for Parents/Carers Children s Services Women & Children s Group This leaflet has been designed to give you important information about your condition/procedure, and to answer some
More informationEndoscopy Department Patient Information Gastroscopy with Oesophageal Dilation
Endoscopy Department Patient Information Gastroscopy with Oesophageal Dilation This leaflet provides information about the Endoscopy and Dilation procedure. It aims to answer any questions you may have
More informationAdvance Directive Form
Advance Directive Form NOTE: This form is being provided to you as a public service. The attached forms are provided as is and are not the substitute for the advice of an attorney. By providing these forms
More information~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT
~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document you
More informationHealth Care Directive
Health Care Directive Overview Adults with decision-making capacity have the right to make choices about their health care. No treatments may be given to someone who does not want them. The attached Durable
More informationGastroscopy. Please bring this booklet with you to your appointment. Oesophago-gastro duodenoscopy (OGD)
Gastroscopy Oesophago-gastro duodenoscopy (OGD) Your appointment details, information about the examination, and consent form Please bring this booklet with you to your appointment 1 2 Your appointment
More informationPATIENT INFORMATION & CONDITION FORM
PATIENT INFORMATION & CONDITION FORM Patient Name: Today's Date: / / Social Security Number Birth Date: / / Age: Gender: F M Email Height : Weight: Specify Right or Left Handed Have you ever been in our
More informationIntranet version. Bradford Teaching Hospitals. NHS Foundation Trust. Colonoscopy. Gastroenterology Unit patient information booklet
Intranet version Bradford Teaching Hospitals NHS Foundation Trust Colonoscopy Gastroenterology Unit patient information booklet What is a colonoscopy? A colonoscopy is a procedure generally performed under
More informationDURABLE HEALTH CARE POWER OF ATTORNEY AND HEALTH CARE TREATMENT INSTRUCTIONS (LIVING WILL) PART I INTRODUCTORY REMARKS ON HEALTH CARE DECISION MAKING
DURABLE HEALTH CARE POWER OF ATTORNEY AND HEALTH CARE TREATMENT INSTRUCTIONS (LIVING WILL) PART I INTRODUCTORY REMARKS ON HEALTH CARE DECISION MAKING You have the right to decide the type of health care
More informationAdvance Directive for Health Care
Advance Directive for Health Care respecting your right to: Choose Your Healthcare Agent Choose the Authority Given to Your Healthcare Agent Choose Your Preferences Related to Treatment & Care Printed
More information2
1 2 3 4 Designation of Health Care Surrogate I, (please print) want Phone Address to be my Health Care Surrogate and make health care decisions for me as indicated by my initials below: Effective only
More informationRecognizing and Reporting Acute Change of Condition
Recognizing and Reporting Acute Change of Condition Welcome to the Elizabeth McGowan Training Institute Cell Phones and Pagers Please turn your cell phones off or turn the ringer down during the session.
More informationUpper GI Endoscopy a guide for patients and carers
Upper GI Endoscopy a guide for patients and carers Welcome to the Endoscopy Unit. This information leaflet is intended to provide you with information about an upper endoscopy. It is not expected to cover
More informationRetina Center of Oklahoma Demographic Information Sam S. Dahr,MD
Retina Center of Oklahoma Demographic Information Sam S. Dahr,MD PATIENT LAST NAME: FIRST NAME: MI: MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: DATE OF BIRTH:
More informationEntrance Case History (Please write or print clearly)
Stony Brook Medical Park 2500 Nesconset Highway Suite 4-A Stony Brook, NY 11790 (631) 675-9000 Fax (631) 675-9002 www.naturalapproach.us Entrance Case History (Please write or print clearly) Today s Date
More informationPOWER OF ATTORNEY FOR HEALTH CARE
Wisconsin Right to Life POWER OF ATTORNEY FOR HEALTH CARE Informational Guide The State of Wisconsin Power of Attorney for Health Care Document (DPH 0085, Rev. 6/98) is a form created by the State of Wisconsin
More informationSOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST
SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST CLINICAL SERVICES POLICY & PROCEDURE (CSPP No.21) CONSENT POLICY & PROCEDURE September 2018 DOCUMENT INFORMATION Author: Dave Sherwood Assistant Director
More informationMY VOICE (STANDARD FORM)
MY VOICE (STANDARD FORM) a workbook and personal directive for advance care planning WHAT IS ADVANCE CARE PLANNING? Advance care planning is a process for you to: think about what is important to you when
More informationAbiraterone Acetate (Zytiga )
Abiraterone Acetate (Zytiga ) ( a-bir-a-ter-one AS-e-tate ) How drug is given: By mouth Purpose: To stop the growth of cancer cells in prostate cancer How to take this drug 1. Take this medication on an
More informationAdvance Directive. including Power of Attorney for Health Care
Advance Directive including Power of Attorney for Health Care Overview This is a legal document, developed to meet the legal requirements for Wisconsin. This document provides a way for a person to create
More information