<div class="form-inline">
<style media="screen">
a {word-wrap: break-word;}
.form-group {width: 100%; !important}
.cp_label {font-weight: 900;}
.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}
</style>
<div class="cp_whiteBox">
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_specialRequirements">Special requirements:</label>
<textarea class="form-control" name="cp_specialRequirements" id="cp_specialRequirements" rows="3" style="width: 100%;"></textarea>
<p class="help-block">(e.g. other language/other communication method)</p>
</div>
</div>
<h2>Responsible consultant:</h2><div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_consultName">Name:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_consultName" id="cp_consultName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_consultJob">Job title:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_consultJob" id="cp_consultJob" class="form-control" style="width: 100%;"></input>
</div>
</div>
<h2>Name of proposed course of treatment</h2>
<p>(include brief explanation if medical term not clear. Include regimen/protocol name and list drug names in full. Specify the indication, route, schedule of administration, and location of treatment.)</p>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_regimen">Regimen</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_regimen" id="cp_regimen" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_treatmentIndication">Indication for treatment </label>(i.e. tumour site):
<textarea class="form-control" name="cp_treatmentIndication" id="cp_treatmentIndication" rows="3" style="width: 100%;"></textarea>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_adminRoute">Route(s) of administration:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_adminRouteIntravenous" id="cp_adminRouteIntravenous" value="Intravenous"> Intravenous</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_adminRouteSubcutaneous" id="cp_adminRouteSubcutaneous" value="Subcutaneous"> Subcutaneous</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_adminRouteOral" id="cp_adminRouteOral" value="Oral"> Oral</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_adminRouteOther" id="cp_adminRouteOther:" value="Other:"> Other:</input>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_adminRouteOtherNotes">If Other</label>
<textarea class="form-control" name="cp_adminRouteOtherNotes" id="cp_adminRouteOtherNotes" rows="3" style="width: 100%;"></textarea>
</div>
</div>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_frequency">Frequency </label>(treatment days and length of cycle):
<textarea class="form-control" name="cp_frequency" id="cp_frequency" rows="3" style="width: 100%;"></textarea>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_frequencyDuration">Duration of treatment </label>(number of cycles):
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_frequencyDuration" id="cp_frequencyDuration" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_seperateConsentForm" id="cp_seperateConsentForm" value="A separate consent form must be completed for radiotherapy"> A separate consent form must be completed for radiotherapy</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_participationTrial" id="cp_participationTrial" value="Participation in a clinical trial"> Participation in a clinical trial</input>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_trialName">(trial name)</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_trialName" id="cp_trialName" class="form-control" style="width: 100%;"></input>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_treatmentLocation">Where the treatment will be given:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentLocationOutpatient" id="cp_treatmentLocationOutpatient" value="Outpatient"> Outpatient</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentLocationDayUnit" id="cp_treatmentLocationDayUnit" value="Day unit/case"> Day unit/case</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentLocationInpatient" id="cp_treatmentLocationInpatient" value="Inpatient"> Inpatient</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentLocationOther" id="cp_treatmentLocationOther" value="Other"> Other</input>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_treatmentLocationOtherNote">If other, please define</label>
<textarea class="form-control" name="cp_treatmentLocationOtherNote" id="cp_treatmentLocationOtherNote" rows="3" style="width: 100%;"></textarea>
</div>
</div>
</div>
</div>
<h2>Statement of health professional</h2>
<p>(to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in the hospital /Trust/NHS board's consent policy)</p>
<p>Tick all relevant boxes</p>
<div class="row">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_capacity" id="cp_capacity" value="I confirm the patient has capacity to give consent."> I confirm the patient has capacity to give consent.</input>
</div>
<p>I have explained the course of treatment and intended benefit to the patient.</p>
<h3>The intended benefits</h3>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_curative" id="cp_curative" value="Curative - to give you the best possible chance of being cured."> Curative - to give you the best possible chance of being cured.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_diseaseControl" id="cp_diseaseControl" value="Disease control/palliative - the aim is not to cure but to control or shrink the disease."> Disease control/palliative - the aim is not to cure but to control or shrink the disease.</input>
</div>
<p>The aim is to improve both quality of life and survival.</p>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_adjuvant" id="cp_adjuvant" value="Adjuvant - therapy given after surgery to reduce the risk of the cancer coming back."> Adjuvant - therapy given after surgery to reduce the risk of the cancer coming back.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentLocationOther1" id="cp_treatmentLocationOther1" value="Neo-adjuvant - therapy given before surgery/radiotherapy to shrink the cancer, allow radical treatment and 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.</input>
</div>
</div>
</div>
<h2>Significant, unavoidable or frequently occurring risks (indicate all that apply):</h2>
<div class="row">
<div class="col-sm-12" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_1" id="cp_risks_1" value="This medicine acts on your immune system and may cause inflammation in parts of the body. This can sometimes cause severe side effects which may be life-threatening. It is important that any side effects are treated when they occur to stop them from getting worse. Some side effects begin during treatment but they can sometimes happen months after the last treatment. "> This medicine acts on your immune system and may cause inflammation in parts of the body. This can sometimes cause severe side effects which may be life-threatening. It is important that any side effects are treated when they occur to stop them from getting worse. Some side effects begin during treatment but they can sometimes happen months after the last treatment. </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_2" id="cp_risks_2" value="Tiredness and feeling weak (fatigue). "> Tiredness and feeling weak (fatigue). </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_3" id="cp_risks_3" value="Diarrhoea. "> Diarrhoea. </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_4" id="cp_risks_4" value="Feeling sick (nausea) and being sick (vomiting). "> Feeling sick (nausea) and being sick (vomiting). </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_5" id="cp_risks_5" value="Loss of appetite. Skin reactions and rashes (which can be severe). "> Loss of appetite. Skin reactions and rashes (which can be severe). </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_6" id="cp_risks_6" value="Hair loss or thining of the hair. "> Hair loss or thining of the hair. </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_7" id="cp_risks_7" value="Flu-like symptoms. "> Flu-like symptoms. </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_8" id="cp_risks_8" value="High temperature (fever)."> High temperature (fever).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_9" id="cp_risks_9" value="Infusion-related reactions include allergic reactions (causing a high temperature, chills, shivering (rigors), a headache, and feeling sick (nausea), and pain at the site of the infusion."> Infusion-related reactions include allergic reactions (causing a high temperature, chills, shivering (rigors), a headache, and feeling sick (nausea), and pain at the site of the infusion.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_10" id="cp_risks_10" value="Inflammation in the stomach or intestines (causing stomach pain, diarrhoea, and mucus or blood in the stools). "> Inflammation in the stomach or intestines (causing stomach pain, diarrhoea, and mucus or blood in the stools). </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_11" id="cp_risks_11" value="Inflammation of the liver. "> Inflammation of the liver. </input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_12" id="cp_risks_12" value="Inflammation of the nervous system (causing muscle weakness, and numbness and tingling in the hands and feet)."> Inflammation of the nervous system (causing muscle weakness, and numbness and tingling in the hands and feet).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_13" id="cp_risks_13" value="Inflammation of the lungs (causing breathlessness and cough)."> Inflammation of the lungs (causing breathlessness and cough).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_14" id="cp_risks_14" value="Inflammation of the pancreas. Inflammation of the kidneys."> Inflammation of the pancreas. Inflammation of the kidneys.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_15" id="cp_risks_15" value="Inflammation of the eyes (causing blurred vision and eye pain)."> Inflammation of the eyes (causing blurred vision and eye pain).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_16" id="cp_risks_16" value="Inflammation of hormone producing glands (causing underactive function of the thyroid, adrenal and/or pituitary gland)."> Inflammation of hormone producing glands (causing underactive function of the thyroid, adrenal and/or pituitary gland).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_17" id="cp_risks_17" value="Some side effects are permanent and require long term or life time hormone replacement."> Some side effects are permanent and require long term or life time hormone replacement.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_18" id="cp_risks_18" value="Inflammation of the joints (arthritis)."> Inflammation of the joints (arthritis).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_19" id="cp_risks_19" value="Inflammation of the heart muscle (causing increase in heart beat and abnormal heart rhythms)."> Inflammation of the heart muscle (causing increase in heart beat and abnormal heart rhythms).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_20" id="cp_risks_20" value="Impaired kidney function. Impaired liver function."> Impaired kidney function. Impaired liver function.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_21" id="cp_risks_21" value="Problems with sleep. Unstable blood sugars."> Problems with sleep. Unstable blood sugars.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_22" id="cp_risks_22" value="Blood pressure changes."> Blood pressure changes.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_23" id="cp_risks_23" value="Some side effects may need to be treated with high dose steroids or other immunosuppressive drugs."> Some side effects may need to be treated with high dose steroids or other immunosuppressive drugs.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_24" id="cp_risks_24" value="Cancer can increase your risk of developing a blood clot (thrombosis)."> Cancer can increase your risk of developing a blood clot (thrombosis).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_25" id="cp_risks_25" value="A blood clot may cause pain, redness and swelling in a leg, or breathlessness and chest pain - you must tell your doctor straight away if you have any of these symptoms."> A blood clot may cause pain, redness and swelling in a leg, or breathlessness and chest pain - you must tell your doctor straight away if you have any of these symptoms.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_26" id="cp_risks_26" value="Some anti-cancer medicines possibly can damage women's ovaries and men's sperm. This may lead to infertility in men and women and/or early menopause in women. Early menopause can cause symptoms such as hot flushes, vaginal dryness."> Some anti-cancer medicines possibly can damage women's ovaries and men's sperm. This may lead to infertility in men and women and/or early menopause in women. Early menopause can cause symptoms such as hot flushes, vaginal dryness.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_27" id="cp_risks_27" value="Some anti-cancer medicines may damage the development of a baby in the womb. It is important not to become pregnant or father a child while you are having treatment and for a few months afterwards. It is important to use effective contraception during and for several months after chemotherapy. You can talk to your doctor or nurse about this."> Some anti-cancer medicines may damage the development of a baby in the womb. It is important not to become pregnant or father a child while you are having treatment and for a few months afterwards. It is important to use effective contraception during and for several months after chemotherapy. You can talk to your doctor or nurse about this.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_risks_28" id="cp_risks_28" value="Complications of treatment can very occasionally be life threatening and may result in death. The risks are different for every individual. Potentially life threatening complications include those listed on this form, but, other exceedingly rare side effects may also be life threatening."> Complications of treatment can very occasionally be life threatening and may result in death. The risks are different for every individual. Potentially life threatening complications include those listed on this form, but, other exceedingly rare side effects may also be life threatening.</input>
</div>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_otherRiskInfo">Other risks and information:</label>
<textarea class="form-control" name="cp_otherRiskInfo" id="cp_otherRiskInfo" rows="3" style="width: 100%;"></textarea>
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentBenefit" id="cp_treatmentBenefit" value="I have discussed the intended benefits of the treatment advised and risks of any available alternative treatments (including no treatment)."> I have discussed the intended benefits of the treatment advised and risks of any available alternative treatments (including no treatment).</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_sideEffects" id="cp_sideEffects" value="I have discussed the side effects of the treatment advised, which could affect the patient straight away or in the future, and that there may be some side effects not listed because they are rare or have not yet been reported. Each patient may experience side effects differently."> I have discussed the side effects of the treatment advised, which could affect the patient straight away or in the future, and that there may be some side effects not listed because they are rare or have not yet been reported. Each patient may experience side effects differently.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentAppointments" id="cp_treatmentAppointments" value="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 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.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentStop" id="cp_treatmentStop" value="I have explained to the patient, that he/she has the right to stop this treatment at any time and should contact the responsible consultant or team if they wish to do so."> I have explained to the patient, that he/she has the right to stop this treatment at any time and should contact the responsible consultant or team if they wish to do so.</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_treatmentConcerns" id="cp_treatmentConcerns" value="I have discussed concerns of particular importance to the patient in regard to treatment"> I have discussed concerns of particular importance to the patient in regard to treatment</input>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_treatmentConcernsDetails">(please write details here):</label>
<textarea class="form-control" name="cp_treatmentConcernsDetails" id="cp_treatmentConcernsDetails" rows="3" style="width: 100%;"></textarea>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_clinicalMnagementProtocol">Clinical management guideline/Protocol compliant </label>(please select):
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_clinicalManagementProtocol" id="cp_clinicalManagementProtocolYess" value="Yes"> Yes</input>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_clinicalManagementProtocol" id="cp_clinicalManagementProtocolNo" value="No"> No</input>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="cp_clinicalManagementProtocol" id="cp_clinicalManagementProtocolNotAvailable" value="Not available"> Not available</input>
</div>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_clinicalManagementProtocolNo">If No please document reason here:</label>
<textarea class="form-control" name="cp_clinicalManagementProtocolNo" id="cp_clinicalManagementProtocolNo" rows="3" style="width: 100%;"></textarea>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_providedLeaflets">The following leaflet has been provided:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_providedLeaflets1" id="cp_providedLeaflets1" value="Information leaflets for:"> Information leaflets for:</input>
</div>
<input type="text" class="form-control" name="cp_providedLeaflets1Name" id="cp_providedLeaflets1Name" placeholder="identify here"></input>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_providedLeaflets2" id="cp_providedLeaflets2" value="Unlicensed medicine use information (when relevant)"> Unlicensed medicine use information (when relevant)</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_providedLeaflets3" id="cp_providedLeaflets3" value="24 hour chemotherapy service contact details"> 24 hour chemotherapy service contact details</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_providedLeaflets4" id="cp_providedLeaflets4" value="SACT treatment record (http://cruk.org/treatment-record )"> SACT treatment record (http://cruk.org/treatment-record )</input>
</div>
<div class="form-check">
<input class="form-check-input form-control" type="checkbox" name="cp_providedLeaflets5" id="cp_providedLeaflets5" value="Other"> Other</input>
</div>
<div class="row" style="margin-top: 15px;">
<div class="col-sm-12">
<label class="cp_label" for="cp_providedLeaflets4Stated">please state:</label>
<textarea class="form-control" name="cp_providedLeaflets4Stated" id="cp_providedLeaflets4Stated" rows="3" style="width: 100%;"></textarea>
</div>
</div>
</div>
</div>
<h2>Healthcare professional details:</h2>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_profSigned">Signed:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_profSigned" id="cp_profSigned" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_profSigDate">Date:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_profSigDate" id="cp_profSigDate" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_profName">Name (print):</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_profName" id="cp_profName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_profTitle">Job title:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_profTitle" id="cp_profTitle" class="form-control" style="width: 100%;"></input>
</div>
</div>
<h2>Statement of interpreter</h2>
<p>(where appropriate)</p>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_interpreterBooking">Interpreter booking reference (if applicable):</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_interpreterBooking" id="cp_interpreterBooking" class="form-control" style="width: 100%;"></input>
</div>
</div>
<p>I have interpreted the information above to the patient to the best of my ability and in a way in which I believe they can understand.</p>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_interpreterSigned">Signed:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_interpreterSigned" id="cp_interpreterSigned" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_interpreterSigDate">Date:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_interpreterSigDate" id="cp_interpreterSigDate" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_interpreterName">Name (print):</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_interpreterName" id="cp_interpreterName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_interpreterTitle">Job title:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_interpreterTitle" id="cp_interpreterTitle" class="form-control" style="width: 100%;"></input>
</div>
</div>
<h2>Statement of patient</h2>
<p>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.</p>
<p>I agree to the procedure and course of treatment described on this form.</p>
<p>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.</p>
<p>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.</p>
<p>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:</p>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientSigned">Signed:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_patientSigned" id="cp_patientSigned" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientSigDate">Date:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_patientSigDate" id="cp_patientSigDate" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientName">Name (print):</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_patientName" id="cp_patientName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_patientTitle">Job title:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_patientTitle" id="cp_patientTitle" class="form-control" style="width: 100%;"></input>
</div>
</div>
<p>A witness should sign below if the patient is unable to sign but has indicated their consent. Young people/children may also like a parent to sign here (see notes).</p>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_witnessSigned">Signed:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_witnessSigned" id="cp_witnessSigned" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_witnessSigDate">Date:</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="date" name="cp_witnessSigDate" id="cp_witnessSigDate" class="form-control" placeholder="dd/mm/yyyy"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_witnessName">Name (print):</label>
</div>
<div class="col-sm-6" style="margin-top: 15px;">
<input type="text" name="cp_witnessName" id="cp_witnessName" class="form-control" style="width: 100%;"></input>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<label class="cp_label" for="cp_witnessTitle">Job title:</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_witnessTitle" id="cp_witnessTitle" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label class="cp_label" for="cp_patientAccepted">Copy accepted by patient:</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <div> <div class="form-check"> <input class="form-check-input" type="radio" name="cp_patientAccepted" id="cp_patientAcceptedYes" value="Yes"> Yes</input> </div> <div class="form-check"> <input class="form-check-input" type="radio" name="cp_patientAccepted" id="cp_patientAcceptedNo" value="No"> No</input> </div> </div> </div> </div> <h2>Confirmation of consent</h2> <p>(health professional to complete when the patient attends for treatment, if the patient has signed the form in advance)</p> <p>On behalf of the team treating the patient, I have confirmed that the patient has no further questions and wishes the course of treatment/procedures to go ahead.</p> <div class="row"> <div class="col-sm-6"> <label class="cp_label" for="cp_consentSigned">Signed:</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_consentSigned" id="cp_consentSigned" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label class="cp_label" for="cp_consentSigDate">Date:</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_consentSigDate" id="cp_consentSigDate" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label class="cp_label" for="cp_consentName">Name (print):</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_consentName" id="cp_consentName" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label class="cp_label" for="cp_consentTitle">Job title:</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_consentTitle" id="cp_consentTitle" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label class="cp_label" for="cp_importantNotes">Important notes: (select if applicable)</label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <div class="form-check"> <input class="form-check-input form-control" type="checkbox" name="cp_importantNotes1" id="cp_importantNotes1" value="See also advance decision to refuse treatment"> See also advance decision to refuse treatment</input> </div> <div class="form-check"> <input class="form-check-input form-control" type="checkbox" name="cp_importantNotes2" id="cp_importantNotes2" value="Patient has withdrawn consent"> Patient has withdrawn consent</input> </div> <div class="row"> <div class="col-sm-12" style="margin-top: 15px;"> <label class="cp_label" for="cp_consentWithdraw">(ask patient to sign /date here)</label> <input type="text" name="cp_consentWithdrawSig" id="cp_consentWithdrawSig" class="form-control" style="width: 100%;"></input> <input type="date" name="cp_consentWithdrawDate" id="cp_consentWithdrawDate" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> </div> </div> <h2>Further information for patients</h2> <div class="row" style="margin-top: 15px;"> <div class="col-sm-12"> <label class="cp_label" for="cp_contactDetails">Contact details </label>(if patient wishes to discuss options later): <textarea class="form-control" name="cp_contactDetails" id="cp_contactDetails" rows="3" style="width: 100%;"></textarea> </div> </div> <p><b>Contact your hospital team if you have any questions about cancer and its treatment.</b></p> <p>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 0808 800 4040, Monday to Friday, 9am to 5pm. Alternatively visit for more information.</p> <p>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.</p> <h3>What a consent form is for</h3> <p>This form documents the patient's agreement to go ahead with the 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 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 should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient.</p> <h3>The law on consent</h3> <p>See the following publications for a comprehensive summary of the law on consent. Consent: Patients and doctors making decisions together, GMC 2008 (available at <a href=" " target="_blank" rel="noopener noreferrer"> </a>), and Reference guide to consent for examination or treatment, Department of Health, 2nd edition 2009 (available at <a href="www.doh.gov.uk" target="_blank" rel="noopener noreferrer">www.doh.gov.uk</a>).</p> <h3>Who can give consent</h3> <p>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 the child will have capacity to give consent for himself or herself.</p> <p>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, someone with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where children are able to give consent for themselves, 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.</p> <h3>When NOT to use this form</h3> <p>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). A patient lacks capacity if they have an impairment or disturbance of the brain, affecting the way their mind works. For example, if they cannot do one of the following:</p> <ul> <li style="list-style:inherit; margin-left: 15px;">understand information about the decision to be made</li> <li style="list-style:inherit; margin-left: 15px;">retain that information in their mind</li> <li style="list-style:inherit; margin-left: 15px;">use or weigh this information as a part of their decision making process, or</li> <li style="list-style:inherit; margin-left: 15px;">communicate their decision (by talking, using sign language or any other means)</li> </ul> <p>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.</p> <p>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.</p> <h3>Information</h3> <p>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.</p> <h3>References</h3> <ol> <li style="list-style:inherit; margin-left: 15px;">Summary of Product Characteristics (SPCs) for individual drugs: <a href=" " target="_blank" rel="noopener noreferrer"><https://www.medicines.org.uk/emc</a>></li> <li style="list-style:inherit; margin-left: 15px;">Cancer Research UK: <a href="https://www.cancerresearchuk.org/aboutcancer/cancer-in-general/treatment/cancer-drugs" target="_blank" rel="noopener noreferrer"><https://www.cancerresearchuk.org/aboutcancer/cancer-in-general/treatment/cancer-drugs</a>></li> <li style="list-style:inherit; margin-left: 15px;">Macmillan Cancer Support: <a href="https://www.macmillan.org.uk/information-and-support/treating/chemotherapy/drugs-andcombination-regimens" target="_blank" rel="noopener noreferrer"><https://www.macmillan.org.uk/information-and-support/treating/chemotherapy/drugs-andcombination-regimens</a>></li> <li style="list-style:inherit; margin-left: 15px;">Guy's and St. Thomas' NHS Foundation Trust, Chemotherapy consent forms.</li> </ol> </div></div>