PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
|
|
|
- Jordan Flowers
- 5 years ago
- Views:
Transcription
1 PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Abiraterone + Prednisolone PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP: MALE FEMALE SPECIAL REQUIREMENTS: (e.g. other language/other communication method) RESPONSIBLE HEALTH PROFESSIONAL: Name: NAME OF PROPOSED COURSE OF TREATMENT (include brief explanation if medical term not clear) Abiraterone and prednisolone for the treatment of prostate cancer. Abiraterone tablets are taken orally once a day, prednisolone tablets are taken orally twice a day, treatment is supplied every 28 days (one cycle). Treatment is continued until disease progression or unacceptable toxicity. WHERE THE TREATMENT WILL BE GIVEN: outpatient day unit/case inpatient other: STATEMENT OF HEALTH PROFESSIONAL (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in the hospital/trust s consent policy) I have explained the procedure/treatment to the patient. In particular, I have explained: all relevant boxes THE INTENDED BENEFITS CURATIVE to give you the best possible chance of being cured. DISEASE CONTROL/PALLIATIVE the aim is not to cure but to control or shrink the disease. The aim is to improve both quality of life and survival. ADJUVANT therapy given after surgery to reduce the risk of the cancer coming back. NEO-ADJUVANT therapy given before surgery/radiotherapy to shrink the cancer, allow radical treatment and reduce the risk of the cancer coming back. Page 1 of 5
2 STATEMENT OF HEALTH PROFESSIONAL (continued) SIGNIFICANT, UNAVOIDABLE OR FREQUENTLY OCCURRING RISKS COMMON SIDE EFFECTS: More than 10 in every 100 (>10%) people have one or more of the side effects listed: High blood pressure during treatment, diarrhoea, tiredness and feeling weak (fatigue) and fluid retention (you may notice you gain weight and/ or your ankles and legs swell). Changes in blood tests used to monitor electrolytes (potassium). An increased risk of getting a urinary tract infection (you may experience aches or pains in the muscles, pain when passing urine, cloudy or smelly urine, a high temperature and chills) OCCASIONAL SIDE EFFECTS: Between 1 and 10 in every 100 (1-10%) people have one or more of these effects: Heart problems including heart failure, chest pain and atrial fibrillation (fast and irregular heartbeats), hot flushes, indigestion, abdominal (tummy) pain, feeling sick (nausea), small amounts of blood in the urine, skin rash, raised cholesterol and other blood fats, and the development of infections. Changes in blood tests used to monitor the liver function. A decrease in bone density (bone thinning, osteoporosis) can make your bones more prone to break (fracture). OTHER RISKS: Uncommon and rare side effects include pain in the muscles and joints, muscle weakness, reduced activity of the adrenal gland (adrenal insufficiency), liver failure and inflammation of the lung tissue causing breathing problems. Long term use of steroids (prednisolone) may cause irritation of the stomach lining, increase your appetite, cause changes in blood sugar levels, fluid retention, changes in behaviour (mood swings, difficulty sleeping, anxiety or irritability), eye changes, Cushing s syndrome (acne, puffiness of the face, dark marks on the skin), muscle wasting and bone thinning (osteoporosis). Some anti-cancer medicines can damage men s sperm. This may lead to infertility in men. Some anti-cancer medicines may damage the development of a baby in the womb. It is important not father a child while you are having treatment and for up to 6 months afterwards. It is important to use effective contraception (e.g. barrier methods) during and for up to 6 months after treatment. You can talk to your doctor or nurse about this. Very rarely complications of treatment with anticancer medicines can be life-threatening or even result in death. The risks are different for every individual. You can talk to your doctor or nurse about what this means for you. Page 2 of 5
3 STATEMENT OF HEALTH PROFESSIONAL (continued) ANY OTHER RISKS: I have discussed what the treatment is likely to involve (including inpatient / outpatient treatment, timing of the treatment, blood and any additional tests, follow-up appointments etc) and location. I have discussed the intended benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. THE FOLLOWING LEAFLET HAS BEEN PROVIDED: Information leaflet for abiraterone hormonal therapy. 24 hour chemotherapy service contact details Other, please state: STATEMENT OF INTERPRETER (where appropriate) INTERPRETER BOOKING REFERENCE (if applicable): 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. Page 3 of 5
4 STATEMENT OF PATIENT Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of the form 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: 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). Parent s/witness signature: COPY ACCEPTED BY PATIENT: YES / NO (please circle) CONFIRMATION OF CONSENT (health professional to complete when the patient attends for treatment, 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. IMPORTANT NOTES: (tick if applicable) See also advance decision to refuse treatment Patient has withdrawn consent (ask patient to sign /date here) FURTHER INFORMATION FOR PATIENTS CONTACT DETAILS (if patient wishes to discuss options later): Contact your hospital team if you have any questions about cancer and treatment. Cancer Research UK can also help answer your questions about cancer and treatment. If you want to talk in confidence, call our information nurses on freephone , Monday to Friday, 9am to 5pm. Alternatively visit for more information. These forms have been produced by Guy s and St. Thomas NHS Foundation Trust as part of a national project to support clinicians in ensuring all patients are fully informed when consenting to SACT. The project is supported by Cancer Research UK. This does not mean you are taking part in a clinical trial. Page 4 of 5
5 GUIDANCE FOR HEALTH PROFESSIONALS (to be read in conjunction with the hospital s 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-memoir to health professionals and patients, by providing a checklist 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 2nd Edition for a comprehensive summary of the law on consent (also available at WHO CAN GIVE CONSENT Everyone aged 16 or over 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 capacity to give consent for himself or herself. Young people aged 16 and 17, and younger children with capacity, 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, someone 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 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 an alternative form (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 this information as a part of their 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 do so under a Lasting Power of Attorney or as a court 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 significant, unavoidable 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 the consent form or in the patient s notes. REFERENCES 1. Summary of Product Characteristics (SPCs) for individual drugs: 2. Cancer Research UK: about-cancer/cancers-in-general/treatment/cancer-drugs/ 3. Macmillan Cancer Support, Cancer Information: macmillan.org.uk/cancerinformation/cancertreatment/ Treatmenttypes/Chemotherapy/Chemotherapy.aspx 4. Guy s and St. Thomas NHS Foundation Trust, Chemotherapy consent forms. Page 5 of 5
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: 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: 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: 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 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: 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: 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 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 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 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 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 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 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 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 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 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
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
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 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
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 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 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
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
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
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
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
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
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
Congestive Heart Failure
TM Nightingale Congestive Heart Failure Do you or someone you know have any of the following symptoms? 1. Shortness of breath (dyspnea) when you exert yourself or when you lie down 2. Swelling in your
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
Patient information. Breast Reconstruction TRAM Breast Services Directorate PIF 102 V5
Patient information Breast Reconstruction TRAM Breast Services Directorate PIF 102 V5 Your consultant has recommended that you have a TRAM flap to reconstruct your breast. TRAM stands for Transverse Rectus
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
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
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
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
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
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
Flossmoor: (708) Harvey: (708) Tinley Park: (708) ICOR: (708) Crestwood: (708) Patient Signature:
Patient Information Guidelines Department of Outpatient Therapy Services Physical, Speech and Occupational Therapy The staff at Ingalls Outpatient Therapy Services Department is dedicated to providing
Wirral 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
DAILY ACTIVITIES (Q1)
THE QUESTIONS OF HOWSYOURHEALTH ADULT AND SCORING CONVENTIONS 1/2017 * ARE USED IN THE CALCULATION SHOWN IN THE CUMULATIVE REPORTS ++ ARE USED IN THE WHAT MATTERS INDEX Gender: Male Female Age Groups:
CNA SEPSIS EDUCATION 2017
CNA SEPSIS EDUCATION 2017 WHAT CAUSES SEPSIS? Sepsis occurs when the body has a severe immune response to an infection Anyone who has an infection is at risk for developing sepsis Sepsis occurs when the
Last 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
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:
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
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?
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
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
Seasons Women s Care Patient Registration Form
Seasons Women s Care Patient Registration Form Name: of Birth: Address: City: St: Zip Home Phone: Cell: Best Number: Email: Race or Ethnicity: Marital Status: SS# Drivers Lic#: Employer: Work# Occupation:
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
Oxford Orthoptic Service, Oxford Eye Hospital Children s Day Care Ward, The Children s Hospital. Squint surgery for children
Oxford Orthoptic Service, Oxford Eye Hospital Children s Day Care Ward, The Children s Hospital Squint surgery for children This leaflet has been written to give you information about surgical correction
NHS 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...
Last 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
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:
The Home Doctor. Registration Checklist
The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this
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
Advance 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...
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.
Diagnostic 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
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
Surgical Treatment for Cancer of the Oesophagus
Oxford Oesophagogastric Centre Surgical Treatment for Cancer of the Oesophagus Information for patients This leaflet gives you information about your planned operation, possible risks and complications,
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
MRSA INFORMATION LEAFLET for patients and relatives. both in hospital and the community. MRSA is a type of
MRSA INFORMATION LEAFLET for patients and relatives WHAT DOES MRSA STAND FOR? Meticillin Resistant Staphylococcus aureus. WHAT IS MRSA? Staphylococcus aureus is a germ that is commonly found both in hospital
Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#
PATIENT WILL NOT BE SEEN WITHOUT PHOTO ID Patient Information Kimberly Walpert, M.D. 1199 Prince Avenue Athens GA 30606 Ph 706-475-1870 Fax 706-475-1879 www.athensbrainandspine.com Patient Name First Middle
Patient information. Axillary Node Surgery (Operations on the Armpit) Breast Directorate PIF 1370 V3
Patient information Axillary Node Surgery (Operations on the Armpit) Breast Directorate PIF 1370 V3 What is Axillary Node Surgery? As part of any breast cancer operation the surgeon will usually remove
Your annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.
Dear: Your annual preventive visit, or complete physical exam, is scheduled with Dr. on at AM/PM. Please bring the following with you on the date of your appointment: A list of your current medication(s),
Decisions about Cardiopulmonary Resuscitation (CPR)
Decisions about Cardiopulmonary Resuscitation (CPR) Information for patients and those close to them This leaflet is about Cardiopulmonary Resuscitation (CPR) and how decisions are made about it. This
My 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
University College London Hospitals (UCLH) Preventing venous thromboembolism (VTE)
University College London Hospitals (UCLH) Preventing venous thromboembolism (VTE) Information for adult inpatients and for patients due to be admitted If you need a large print, audio, braille, easy read
Health care services for Asylum Seekers in Sheffield
Health care services for Asylum Seekers in Sheffield Information Leaflet The Clover Group Practice is a directly managed multidisciplinary NHS practice. It is managed by and is accountable for its systems
CURE CARDIOVASCULAR CONSULTANTS
NEW PATIENT PACKET There are six pages in this packet that will help us get a clearer picture of your medical history and physical health. Please note: SIGNATURES are required on pages 2, 4, and 6. Please
ADVANCE 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.
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
Information for patients receiving long term hormone treatment and radiotherapy for prostate cancer
Information for patients receiving long term hormone treatment and radiotherapy for prostate cancer Northern Centre for Cancer Care (NCCC) Freeman Hospital Introduction This leaflet has been written to
Last Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone
Last Name First Middle Mailing Address City State Zip Phone Date of Birth Age Soc. Sec# Cell Employer Work Phone Email Address Emergency contact Phone # Relation: Name of Primary Insurance Policy # -----
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
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB. Please answer the following questions about your current eye problems and medical history:
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB Please answer the following questions about your current eye problems and medical history: 1. What problems are you CURRENTLY having with your
The Children s Hospital Children s Day Care Ward, Tom s Ward. Labial Adhesions. Information for parents and carers
The Children s Hospital Children s Day Care Ward, Tom s Ward Labial Adhesions Information for parents and carers What are labial adhesions? Labial adhesions (sometimes known as labial fusion) occur when
UW MEDICINE PATIENT EDUCATION. Angiography: Radiofrequency Ablation to Treat Solid Tumor. What to expect. What is radiofrequency ablation?
UW MEDICINE PATIENT EDUCATION Angiography: Radiofrequency Ablation to Treat Solid Tumor What to expect This handout explains radiofrequency ablation and what to expect when you have this treatment for
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
You and your Totally Implanted Vascular Access Device (TIVAD) - Portacath
You and your Totally Implanted Vascular Access Device (TIVAD) - Portacath Nursing A guide for patients and carers Contents What is a TIVAD?... 1 Why is a TIVAD necessary?... 2 How a TIVAD is inserted...
Recovering from a hip fracture following an accident
South Tyneside NHS Foundation Trust Recovering from a hip fracture following an accident Providing a range of NHS services in Gateshead, South Tyneside and Sunderland. What is a hip fracture? The hip joint
Common words and phrases
Information Line: 0800 999 2434 Website: compassionindying.org.uk This is a guide to some words and phrases you may hear when planning ahead for your future care and treatment. If you have any questions
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
CHPCA 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
Bowel Surgery Panproctocolectomy Your operation explained
Bowel Surgery Panproctocolectomy Your operation explained Introduction This information is for people considering having a Panproctocolectomy operation. It explains what is involved and some possible problems
Having an open radical nephrectomy
Having an open radical nephrectomy Your doctor has recommended that you have a nephrectomy an operation to remove your kidney. This leaflet aims to answer your questions and explains the benefits, risks
Instruction 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
The process has been designed to be user friendly and involves a few simple steps.
HOW DO I ENROLL A PATIENT WITH HOUSECALL MD? The process has been designed to be user friendly and involves a few simple steps. It is the patient s/family s/dpoa s/guardian s decision, if they want to
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
Enhanced Recovery Programme for total hip and knee replacement Orthopaedic Department Patient Information Leaflet
Enhanced Recovery Programme for total hip and knee replacement Orthopaedic Department Patient Information Leaflet What is the Enhanced Recovery Programme? This leaflet aims to give you information on what
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.
Insertion of a ventriculo-peritoneal or ventriculo-atrial shunt
Department of Neurosurgery Insertion of a ventriculo-peritoneal or ventriculo-atrial shunt Information for patients Shunt surgery This leaflet explains what to expect when you are in hospital and during
INFORMATION 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
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