Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ABVD. Patient s first names.
|
|
|
- Maximillian Baker
- 5 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 Hodgkin s Disease ABVD Doxorubicin/Bleomycin/Vinblastine/ Dacarbazine Responsible health professional Job title Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) ABVD chemotherapy Intravenous Doxorubicin, Bleomycin, Vinblastine and Dacarbazine on day 1 and day 14 Every 28 days for 4 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: Doxorubicin, Vinblastine and Dacarbazine may leak into the tissue around the vein while it is being given causing stinging and burning around the vein. You may suffer with fever and chills a few hours after the Bleomycin is given. Bleomycin can also cause the skin to darken, but it will go back to normal a few months after completion of treatment. Bleomycin can cause serious lung problems. If you experience symptoms of shortness of breath or a cough, report this to your doctor immediately. Vinblastine can cause numbness or tingling in hands or feet. It can also cause constipation and abdominal cramps, but in some people, it may cause diarrhoea. 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. You may experience facial flushing while Dacarbazine is being given. During treatment with Dacarbazine and for several months afterwards you may be more sensitive to the sun. You may also experience flu-like symptoms (headache, aching joints or muscle, high temperature, weakness and chills) up to a week after you have had Dacarbazine. Dacarbazine may temporarily affect the way your liver functions. This will be monitored during treatment by blood tests.
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 ABVD 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 AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM FERRERI / IELSG PROTOCOL. Patient s first names. Date of birth
Page 1 of 6 FORM FERRERI / IELSG PROTOCOL 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
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CISPLATIN + ETOPOSIDE ORAL/INTRAVENOUS
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CISPLATIN + ETOPOSIDE ORAL/INTRAVENOUS 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 CHOP 21 +/- RITUXIMAB. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 +/- RITUXIMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital
Patient identifier/label: Page 1 of 7 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM EC-T: EPIRUBICIN / CYCLOPHOSPHAMIDE - DOCETAXEL
Patient identifier/label: Page 1 of 7 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM EC-T: EPIRUBICIN / CYCLOPHOSPHAMIDE - DOCETAXEL Patient s surname/family name Patient s first names Date of birth
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CYTARABINE (HIGH DOSE)
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 CABOZANTINIB. Patient s first names.
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CABOZANTINIB Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number (or other
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM BEVACIZUMAB. Patient s first names. Date of birth.
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM BEVACIZUMAB 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 ZOLEDRONIC ACID. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ZOLEDRONIC ACID Patient s surname/family name Patient s first names Date of birth NHS number (or other identifier)
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: BEP (5 day) 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: Carboplatin-Etoposide 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: FEC-P PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP: MALE
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Nintedanib-Docetaxel 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: Docetaxel-EC 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: Gemcitabine- Carboplatin 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: Cisplatin- Capecitabine- Trastuzumab 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: Oxaliplatin- Fluorouracil (FOLFOX) 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: Docetaxel-Oxaliplatin- Fluorouracil (FLOT) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Irinotecan- Capecitabine (CAPIRI) 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: Dabrafenib-Trametinib 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: Everolimus 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: Niraparib 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: Atezolizumab 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: Pazopanib 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: Pembrolizumab 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: Bevacizumab + Chemotherapy 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: Sunitinib 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: Axitinib 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: Ponatinib 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: Zoledronic acid 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's surname/family name. Patient's first names. Date of birth. Responsible health professional. Job title. NHS number (or other identifier)
Page 1 of7 Patient's surname/family name Department of Health THE ROYAL MARSDEN NHS FOUNDATION TRUST Robotic-assisted Laparoscopic Prostatectomy (RALP) Patient Agreement to Investigation or Treatment Patient's
Patient agreement to investigation or treatment. Emergency Spinal Discectomy/Decompression. Patient details (or pre-printed label)
CONSENT FORM 1 (VI) Patient agreement to investigation or treatment Emergency Spinal Discectomy/Decompression Patient details (or pre-printed label) Patient s surname/family name..... Patient s first names..
Patient agreement to investigation or treatment. Spinal Injections. Patient details (or pre-printed label) Patient s surname/family name...
CONSENT FORM 1(VII) Patient agreement to investigation or treatment Spinal Injections Patient details (or pre-printed label) Patient s surname/family name..... Patient s first names.. Date of birth. Responsible
ABVD. by infusion over 30 minutes. You will have treatment on Day 1 and Day 15 (this is one cycle) for 2, 3 or 6 cycles.
ABVD ABVD This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
Fitting of an Intrauterine Device (IUD)
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is an IUD? An IUD is a small T-shaped plastic and copper device that is put into
ABVD. by infusion over 30 minutes. You will have treatment on Day 1 and Day 15 of a 28 day cycle. You will have 2, 3 or 6 cycles.
ABVD ABVD This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
Gemcitabine and Cisplatin (urology)
Gemcitabine and Cisplatin Gemcitabine and Cisplatin (urology) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce
Paclitaxel (Taxol) and carboplatin
Paclitaxel (Taxol) and carboplatin Paclitaxel (Taxol) and carboplatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Pentostatin (Nipent )
Pentostatin (Nipent ) Pentostatin (Nipent ) This leaflet is offered as a guide to you and your family. Your treatment will be fully explained by your doctor or nurse, who will be happy to answer any questions.
Percutaneous nephrolithotomy (PCNL)
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What does this procedure involve? The breakdown and removal of kidney stones using
Oral cyclophosphamide in ovarian cancer
Oral cyclophosphamide in ovarian cancer Oral cyclophosphamide in ovarian cancer This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy
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
Weekly standard dose. Paclitaxel (Taxol) and carboplatin
paclitaxel (taxol) and carboplatin Paclitaxel (Taxol) and carboplatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
GCVP. Cyclophosphamide by injection Vincristine by short infusion. Gemcitabine by infusion over 30 minutes
GCVP GCVP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
Diagnostic and therapeutic pleural aspiration
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient Diagnostic and therapeutic pleural aspiration affix patient label Who is this leaflet for? This leaflet
Carboplatin & weekly paclitaxel (Taxol) (for anal cancer) Carboplatin and weekly paclitaxel (Taxol) (for anal cancer)
Carboplatin & weekly paclitaxel (Taxol) (for anal cancer) Carboplatin and weekly paclitaxel (Taxol) (for anal cancer) The possible benefits of treatment vary; for some people chemotherapy may reduce the
Gemcitabine and carboplatin (Breast)
Gemcitabine and carboplatin (Breast) Gemcitabine and carboplatin (Breast) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy
Mitomycin C given by injection into a vein. Cisplatin and hydration (fluids) via a drip over 6 or 18 hours.
Cisplatin & Mitomycin C Cisplatin & Mitomycin C This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Vinblastine (Lymphoma)
Vinblastine (Lymphoma) Vinblastine (Lymphoma) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Brentuximab vedotin. Brentuximab vedotin
Brentuximab vedotin Brentuximab vedotin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Laparoscopic radical nephrectomy
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a laparoscopic radical nephrectomy? This is a procedure which involves removal
Paclitaxel (Taxol) Paclitaxel is given into the vein (intravenously) through a fine tube (cannula) as an infusion over 1 hour.
Paclitaxel (Taxol) Paclitaxel (Taxol) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Myocet. Myocet. Myocet is given into the vein (intravenously) through a fine tube (cannula) as an infusion over 1 hour.
Myocet Myocet This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
West Suffolk Hospital
For staff use only: Patient Details: First names: Hospital no: (Use hospital identification label) West Suffolk Hospital Patient information leaflet Carpal Tunnel Syndrome 2-3 Patient agreement to investigation
Bendamustine. Bendamustine. Your treatment Your doctor or nurse clinician has prescribed a course of treatment with bendamustine.
Bendamustine Bendamustine This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back,
Epirubicin. Epirubicin
Epirubicin Epirubicin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for
Perjeta Contains the active ingredient pertuzumab (rch)
Perjeta Contains the active ingredient pertuzumab (rch) Consumer Medicine Information What is in this leaflet This leaflet answers some common questions about Perjeta. It does not contain all the available
Gemcitabine and carboplatin (Lung)
Gemcitabine and carboplatin (Lung) Gemcitabine and carboplatin (Lung) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
VDC IE. Your treatment You will have 14 cycles of VDC IE given every 2 to 3 weeks.
VDC IE VDC IE This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
Gemcitabine and carboplatin (Lung)
Gemcitabine and carboplatin (Lung) Gemcitabine and carboplatin (Lung) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Myeloma Haematology and Transplant Unit
BCD Myeloma Haematology and Transplant Unit BCD This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Cisplatin and radiotherapy to the
Cisplatin and radiotherapy to the head and neck Cisplatin and radiotherapy to the head and neck This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some
GDP GDP Gemcitabine, Dexamethasone, CisPlatin Your treatment Day 1 Days 1 to 4 Day 8 dexamethasone
GDP GDP Gemcitabine, Dexamethasone, CisPlatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Docetaxel (Taxotere) with GCSF
Docetaxel (Taxotere) with GCSF Docetaxel (Taxotere) with GCSF for hormone This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy
ChIVPP. ChIVPP. Day 1 to 14 Chlorambucil tablets Procarbazine capsules Prednisolone tablets
ChIVPP ChIVPP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
The treatment is given every 3 weeks for 6 to 8 cycles.
R-CVP R-CVP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it
Your treatment. 240 BEP 3 Days Page 1 of 6
BEP - 3 Days BEP - 3 Days This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back,
VIDE. Vincristine given via intravenous (IV) infusion over 10 minutes Etoposide & doxorubicin given together via IV infusion over 4 hours
VIDE VIDE This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
Sorafenib (Nexavar ) For thyroid carcinoma
Sorafenib (Nexavar ) for thyroid carcinoma Sorafenib (Nexavar ) For thyroid carcinoma This leaflet is offered as a guide to you and your family. Sorafenib is a type of anti-cancer treatment called a targeted
Eribulin (Halaven ) Treatment is given on Day 1 and Day 8 of a 21-day cycle.
Eribulin (Halaven ) Eribulin (Halaven ) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Myeloma Haematology and Transplant Unit CTD1
CTD1 Myeloma Haematology and Transplant Unit CTD1 This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of
High dose melphalan conditioning for autologous transplant (inpatient) Palatine treatment centre
High dose melphalan conditioning for autologous transplant (inpatient) High dose melphalan conditioning for autologous transplant (inpatient) Palatine treatment centre This leaflet is offered as a guide
Consumer Medicine Information March 2009
March 2009 50 (oxaliplatin 50mg power for injection vial) 100 (oxaliplatin 100mg power for injection vial) What is in this leaflet? This leaflet answers some common questions about Powder for injection.
Cisplatin and gemcitabine (GI)
Cisplatin and gemcitabine (GI) Cisplatin and gemcitabine (GI) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce
Vinorelbine (Oral) Oral Vinorelbine
Oral Vinorelbine Vinorelbine (Oral) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming
Canalplasty / excision of exostoses
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a canalplasty? A canalplasty is an operation to remove exostoses, which are
Doxorubicin & Ifosfamide
Doxorubicin & Ifosfamide Doxorubicin & Ifosfamide This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of
Oral Etoposide (Lymphoma)
Oral Etoposide (Lymphoma) Oral Etoposide (Lymphoma) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk
Transperineal ultrasound-guided biopsy of the prostate gland
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient biopsy of the prostate gland affix patient label What is a transperineal (TP) ultrasound-guided prostate
Bevacizumab (Avastin ) treatment for Neurofibromatosis Type 2 (NF2) Information for patients
Bevacizumab (Avastin ) treatment for Neurofibromatosis Type 2 (NF2) Information for patients This booklet has been written to give you more information about bevacizumab (commonly known as Avastin). This
Methotrexate. You will have a routine blood test before the start of each cycle of treatment.
Methotrexate Methotrexate This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back,
Fractured neck of femur
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a fractured neck of femur? A healthy hip joint is vital to normal walking
Direct Current Cardioversion (DCCV)
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a This is a procedure carried out under a brief anaesthetic, which uses a
ALL Consolidation (cycles 1-4)
ALL Consolidation (Cycles 1-4) ALL Consolidation (cycles 1-4) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce
Department of Clinical Haematology. Chemotherapy. Information for patients. Page 1 of 12
Department of Clinical Haematology Chemotherapy Information for patients Page 1 of 12 You may find this booklet helpful if you or someone close to you is going to have chemotherapy. It explains: what chemotherapy
For the Patient: Fludarabine injection Other names: FLUDARA
For the Patient: Fludarabine injection Other names: FLUDARA Fludarabine (floo-dare-a-been) is a drug that is used to treat many types of cancer. It is a clear liquid that is injected into a vein. Tell
IVAC IVAC (Lymphoma) 1277 IVAC (Lymphoma) Page 1 of 6
IVAC IVAC (Lymphoma) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for
Vincristine by short infusion Doxorubicin by injection Cyclophosphamide by injection Rituximab by an infusion over between 60 minutes to a few hours
R-CHOP R-CHOP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
Eloxatin Oxaliplatin concentrated solution for injection
Eloxatin Oxaliplatin concentrated solution for injection Consumer Medicine Information Please read this leaflet before you are given this medicine. What is in this leaflet This leaflet answers some common
All medicines have risks and benefits. Your doctor has weighed the risks of you being given Mabthera SC against the benefits expected for you.
New Zealand Consumer Medicine Information MABTHERA SC Rituximab 1400 mg solution for subcutaneous injection for non-hodgkin s Lymphoma and 1600mg solution for subcutaneous injection for chronic lymphocytic
Eribulin (Halaven ) Treatment is given on Day 1 and Day 8 of a 21-day cycle.
Eribulin (Halaven ) Eribulin (Halaven ) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Implantation of an Implantable Cardioverter Defibrillator (ICD)
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is an Implantable? Your doctor has recommended that you have an Implantable.
Mastoidectomy or combined approach tympanoplasty
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a cholesteatoma? This is a cyst of skin cells behind your eardrum. As it gets
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
PATIENT INFORMATION LEAFLET
PATIENT INFORMATION LEAFLET Page 1 of 6 PATIENT INFORMATION LEAFLET: INFORMATION FOR THE USER Ganciclovir 500 mg Powder for Infusion * Read all of this leaflet carefully before you start taking this medicine