1707 Atlantic Avenue, Manasquan NJ 08736
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Fax: (732)528-0764

Useful Information - Consent for Chemotherapy Treatment

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My Doctor has explained the risk, benefits, alternatives and side effects of the chemotherapy proposed to treat my disease. I have been told that chemotherapy may be helpful in the treatment of my disease, either for controlling, arresting and/or curing it. I know that unwanted side effects occur with the use of chemotherapy drugs, and on rare occasions patents have had life threatening reactions. I accept that there is no accurate method to test prior to chemotherapy to know how my disease will respond.
 
I understand that chemotherapy is usually given directly into the bloodstream and often requires that a special long-term IV line (venous access device) be placed into a vein for safe infusion of chemotherapy. I have been provided with information about my chemotherapy and the venous device, if it is recommended, for safe chemotherapy infusion.
 
I have had an opportunity to ask my doctor questions about my treatment and he has answered the questions to my satisfaction. I know that I can stop treatment at any time if I chose to do so.
 
I have read and understand this agreement. I give my voluntary consent to be treated according to my doctor’s recommendations.




The drug treatment plan being offered to me consists of the following drugs:
My physician recommends that I receive a venous access device before beginning my chemotherapy treatment. Yes_______________  No________________

Patients Signature ______________________________________________

Witness Name ____________________  Witness Signature _______________________

Physician’s Name __________________  Physician’s Signature____________________

Authorized Representative of Patient _________________________________________

Reason Patient Does Not Sign Consent ________________________________________

Financial agreement has been obtained ________________________________________