Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 + RITUXIMAB
|
|
|
- Maria Floyd
- 6 years ago
- Views:
Transcription
1 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 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 CHOP 21 + Rituximab Cyclophosphamide/Doxorubicin/Vincrisine/ Oral Prednisolone + Rituximab Responsible health professional Job title Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) CHOP-R chemotherapy: Intravenous Cyclophosphamide, Doxorubicin, Vincristine and Rituximab on day 1 Oral Prednisolone on days 1 to 5 Every 21 days for 6 to 8 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, hair loss, loss of appetite, alter the way food tastes, sore mouth and mouth ulcers. 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. Potential side-effects with the anti-sickness medication may include: constipation, headaches, indigestion, difficulty sleeping and agitation.
3 Patient identifier/label: Page 3 of 6 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: Common side-effects of Rituximab include flu-like symptoms (high temperature, chills, muscle aches, tiredness, dizziness and headache), low blood pressure, flushing and a slight allergic reaction (signs of which include skin rashes, itching, feeling of swelling in the tongue or throat, irritation of the nasal passages, wheezing, coughing and breathlessness - in some people the allergic reaction may be more severe). You will notice these symptoms while the drug is given or within 1-3 hours and they are usually most noticeable with the first infusion and are less noticeable with following doses. Rituximab can cause a reduction in the function of the immune system. This can, very rarely, lead the development of infections, especially viral infections. Vincristine and doxorubicin may leak in the tissue around the vein while it is being given causing stinging and burning around the vein. Vincristine can cause constipation and abdominal cramps. It can also cause numbness or tingling in hands or feet. Cyclophosphamide can cause irritation of the bladder, skin changes (skin darkening and increased sensitivity to the sun) and changes in nails. Doxorubicin may cause changes to the way your heart functions and this may need monitoring during your treatment. It may also colour your urine a pink red colour. This is normal and is due to the colour of the doxorubicin injection. Prednisolone 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 leaflet for R-CHOP 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 FMD. Patient s first names.
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
PATIENT 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
Patient 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
Patient 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
Patient 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
Patient 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
Oral 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
PATIENT 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
Patient 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.
Patient 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
Patient 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.
Patient 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
PATIENT 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
PATIENT 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
PATIENT 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)
PATIENT 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
PATIENT 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:
PATIENT 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:
Patient 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
PATIENT 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:
PATIENT 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:
Patient 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
Treatment 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
CONSENT 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
Sentinel 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
SMG 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
Hickman 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
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Patient & 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
Cyclophosphamide 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
PATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:
PATIENT INFORMATION Name: _ DOB: _ Age: Address: _Sex: City: _ State: _ Zip: _ Email address: Cell Phone: _ Home Phone: Work Phone: _ Responsible Party (if different from above) Name: DOB: Address: E-mail:
Cobimetinib (Cotellic ) ( koe-bi-me-ti-nib )
Cobimetinib (Cotellic ) ( koe-bi-me-ti-nib ) How drug is given: by mouth Purpose: to stop the growth of melanoma cancer cells How to take this drug 1. This drug can be taken with or without food. 2. Swallow
Generator 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
New 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
Bladder Instillation Therapy (Mitomycin) Department of Urology Information for patients
Bladder Instillation Therapy (Mitomycin) Department of Urology Information for patients i Introduction Your consultant has prescribed a course of treatment for you called bladder instillation therapy.
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
Having 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
Etoposide (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
Retina 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:
Pediatric New Patient Form
Pediatric New Patient Form Internal Medicine & Pediatrics Patient Information Today's Date: Legal Name: Gender: M / F Date of Birth: Age: Race : Ethnicity: E-mail Address: Other: Home Address: Primary
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.
WELCOME 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
ALASKA COMMUNITY HEALTH AIDE/PRACTITIONER PROGRAM Standing Orders
CHA/P Name: Village: Tribal Health Organization: is authorized to treat patients with the CHAM ASSESSMENTS that are initialed below according to the PLAN listed in the 2006 Alaska Community Health Aide/Practitioner
Patient 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
Care 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?
Infliximab 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
Top 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
About 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
Children 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
PATIENT REGISTRATION FORM
Natalie A. Nealeigh, PA-C PATIENT REGISTRATION FORM PATIENT INFORMATION (PLEASE PRINT) Last Name: First Name: MI: Street Address: City: State: Zip: Home #: Cell #: Work #: DOB: Age: Sex (M/F): Marital
PATIENT INFORMATION SHEET:
PATIENT INFORMATION SHEET: LAST NAME: FIRST NAME/MI: ADDRESS: CITY: STATE: ZIP CODE: SOCIAL SECURITY #: HOME: CELL: WORK: SEX: M F BIRTHDATE: MARITAL STATUS: SINGLE MARRIED WIDOWED OTHER EMPLOYER NAME:
Recognizing 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.
Harvoni for the treatment of Hepatitis C
Harvoni for the treatment of Hepatitis C Department of Hepatology Digestive Diseases Centre Patient Information This leaflet is designed to give you important information about your new medicine. It is
Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group
DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group Date: NAME: AGE: DOB: Why are you here to see the doctor today? REFERRED BY: INSURANCE HEALTH GRADES INTERNET FRIENDS/RELATIVES PCP OTHER: Medications
Infliximab Infusion for Patients with Crohns Disease Patient Information Leaflet
Infliximab Infusion for Patients with Crohns Disease Patient Information Leaflet Originator: Lindsey Wood Date: March 2011 Version: 2 Date for Review: March 2014 DGOH Ref No: DGOH/PIL/00303 2 Contact Numbers
TEACHER S GUIDE: Peel Public Health School-Based Immunization Clinics
Peel Public Health School-Based Immunization Clinics Immunization Information Peel Public Health provides school-based immunization clinics for grade 7 and 8 students in the region of Peel. Grade 7 students
Methylprednisolone 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
Individualised 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,
Bowel 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
Abbvie 3D for the treatment of Hepatitis C Genotype 1
Abbvie 3D for the treatment of Hepatitis C Genotype 1 Department of Hepatology Digestive Diseases Centre Patient Information This leaflet is designed to give you important information about your new medicine.
WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
EMPOWERING YOU a guide for caregivers. Tom D. EMPLICITI caregiver I ll always provide help, love, and support
EMPOWERING YOU a guide for caregivers Tom D. EMPLICITI caregiver I ll always provide help, love, and support Denise N. EMPLICITI caregiver Letting him know how much he s loved caring for a loved one is
PATIENT 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
TREATMENT JOURNAL. Helping you stay on track SELECT IMPORTANT SAFETY INFORMATION
TREATMENT JOURNAL Helping you stay on track Acthar is a prescription medicine for the reduction of proteinuria in people with nephrotic syndrome of the idiopathic type (unknown origin) without uremia (accumulation
Having 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?
Trans 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
Emergency Care for Blood and Marrow Transplant Patients
PATIENT EDUCATION patienteducation.osumc.edu Emergency Care for Blood and Marrow Transplant Patients General Guidelines for Emergency Care Use these guidelines to know when and how to report any problems
COLON & RECTAL SURGERY, INC.
COLON & RECTAL SURGERY, INC. Please complete attached paperwork and bring to your appointment with your insurance card, co-pay and photo ID. If a referral is required, please be sure to contact your insurance
Participant Information Sheet Adults
Participant Information Sheet Adults Prediction of Lupus TreAtment response Study (PLANS) Finding factors to help us treat lupus patients better and smarter. We would like to invite you
Subacute Care. 1. Define important words in the chapter. 2. Discuss the types of residents who are in a subacute setting
175 26 Subacute Care 1. Define important words in this chapter 2. Discuss the types of residents who are in a subacute setting 3. List care guidelines for pulse oximetry 4. Describe telemetry and list
Abiraterone 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
Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
Intranet 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
Your Anesthesiologist, Anesthesia and Pain Control
You should avoid having pain after surgery by planning ahead. For example, if you know that you are going to be getting up to do your exercises with the therapist, ask for pain control medication in advance.
Family Handbook. New Diagnosis Guide. Provided through the generosity of
Family Handbook New Diagnosis Guide Provided through the generosity of Acknowledgements EDITORS Jeneane Sullivan MSN, RN Kathryn Tomlinson BSN, RN REVIEWERS COG Group Chair, Peter Adamson MD COG Nursing
Bone marrow aspiration and biopsy
Bone marrow aspiration and biopsy Haematology Oncology Team Patient Information Leaflet Introduction This leaflet is for people who are having a procedure called bone marrow aspiration and a biopsy. It
Coordinating Access to Obtain ZOLINZA
ACT Now: 1-866-363-6379 Coordinating Access to Obtain ZOLINZA Reimbursement Support Services Patient Assistance BEFORE YOU LEAVE, please have your physician s office fax your prescription for ZOLINZA and
DRAFT. WORKING DRAFT Nursing associate skills annexe. Part of the draft standards of proficiency for nursing associates. Page 1
WORKING Nursing associate skills annexe Part of the draft standards of proficiency for nursing associates Page 1 Working draft version of the nursing associate skills annexe, part of the draft nursing
UW MEDICINE PATIENT EDUCATION. What is Yttrium-90 radiotherapy? DRAFT. Why do I need this treatment? How does Y-90 radiotherapy work?
UW MEDICINE PATIENT EDUCATION Angiography: Yttrium-90 Radiotherapy Treatment for liver tumors This handout explains what Yttrium-90 radiotherapy is and what to expect when you have it done. What is Yttrium-90
What 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
FROM THE DESK OF THE SCHOOL NURSE School Year
FROM THE DESK OF THE SCHOOL NURSE School Year 2016-2107 Dear Parents, Our goal is to provide for the health and well being of your child while s/he is attending school. Please read this letter carefully,
Bellevue Neurology PATIENT DEMOGRAPHIC FORM
PATIENT DEMOGRAPHIC FORM Name Today s date / / Last First M.I. Mailing Address Age Number, Street, Apartment Number City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth / / SS # Marital
Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
Having a Day Case TRUS Biopsy (General Anaesthetic) Department of Urology Information for patients
Having a Day Case TRUS Biopsy (General Anaesthetic) Department of Urology Information for patients i The prostate The prostate is a small gland, which is found only men. It is found at the base of the
Martina Khundakar - Senior Clinical Pharmacist Teresa Barnes - Lead Clinical Pharmacist - Specialist Care. Timothy Donaldson, Trust Chief Pharmacist
Policy on Pharmacological Therapies Practice Guidance Note The use of Oral Anti-Cancer Medicines and Oral Methotrexate within - V03 V03 - Issued Issue 1 Dec 15 Planned review December 2018 PPT-PGN 09 Part
Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)
Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs
Tennessee Neurology Specialists Affiliated with Baptist Healthcare Group
Tennessee Neurology Specialists Affiliated with Baptist Healthcare Group Oscar E. Mendez, M.D. Rejane Lisboa, M.D. Williamson Medical Center Tower 4323 Carothers Pkwy, Suite 303 Franklin, TN 37067 Phone:
The Leeds Teaching Hospitals NHS Trust Transplant Patients Discharge training
n The Leeds Teaching Hospitals NHS Trust Transplant Patients Discharge training Information for patients This leaflet is designed to help you and your family understand how to look after your new kidney.
Tenckhoff Catheter Insertion
Tenckhoff Catheter Insertion Information for patients with chronic kidney disease (CKD) who have chosen to have peritoneal dialysis Renal Directorate Produced: May 2010 Review date: May 2012 This leaflet
Upper 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
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? 1. 2. 3. IMPORTANT PLEASE BRING A COMPUTER DISK WITH ANY BRAIN
Paragon Infusion Centers Patient Information
Paragon Infusion Centers Patient Information Please complete the following form as accurately as you are able. Inaccurate and/or incomplete information can delay our ability to authorize your treatments,
Children s Ward Parent/Carer Information Leaflet
Operation to straighten the septum Children s Ward Parent/Carer Information Leaflet Introduction Your child s consultant has suggested that your child has an operation to straighten the septum in their
Open and Laparoscopic Nephrectomy
Open and Laparoscopic Nephrectomy Patient information Delivering the best in care UHB is a no smoking Trust To see all of our current patient information leaflets please visit www.uhb.nhs.uk/patient-information-leaflets.htm