Head & Neck radiotherapyPatient consent to treatment

Patient information

GenesisCare number:

Last name: First name:

Date of birth: Sex: Male: Female:

Address:

Is English the patient’s first language? Yes No

Are there any special requirements e.g. translation services? Please specify Yes No

Course of treatment

External beam radiotherapy to oral cavity/oropharynx: Yes No

External beam radiotherapy to early larynx: Yes No

External beam radiotherapy to advanced larynx/supraglottis: Yes No

External beam radiotherapy to nasopharynx/paranasal sinuses: Yes No

External beam radiotherapy to parotid: Yes No

External beam radiotherapy to hypopharynx: Yes No

External beam radiotherapy to neck: Yes No

Other: Please specify Yes No

The intended benefits

Radical radiotherapy – aimed at tumour eradication: Yes No

Post-operative radiotherapy – aimed at reducing the risk of recurrence by greater than 10%: Yes No

Symptom control: Yes No

Other: Please specify Yes No

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Any other comments/discussion

Previous treatmentIf this treatment overlaps previous radiotherapy treatment or is close to previous radiotherapy treatment (so there is risk of overlap), then common and uncommon side-effects may be more likely.

It may be required under some circumstances to obtain previous records from other healthcare providers to support the intended treatment.

To the patient

You have discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment).

You will be supplied with verbal information and a radiotherapy care plan pack which contains printed information.

There are extra procedures which may be necessary during the initial part of your pathway:

• Photographs for identification and treatment delivery• Permanent skin marks (tattoos)

If a needlestick injury occurs with a staff member we may need to take a blood sample which will then be processed and stored by a third party provider.

Other procedure, please specify:

Common short-term side effects

• Skin redness/irritation • Skin breakdown • Mouth/throat soreness • Fatigue• Ear blockage • Dry mouth • Hoarse voice • Hair loss • Weight loss• Altered/loss of taste • Ringing in ears/hearing loss• Numbness/tingling in hands and feet• Swallowing difficulties/including the need for tube feeding

Uncommon or rare long-term side effects

• Cataract • Dental decay• Jaw bone damage • Hearing changes • Swallowing difficulties • Lymphoedema• Trismus (spasm of the jaw)• Underactive glands (e.g. thyroid or pituitary) • Dry mouth/reduced saliva• Second cancers

GenesisCare is a trading name of Genesis Cancer Care UK Limited. Registered Office: Wilson House, Waterberry Drive, Waterlooville, Hampshire PO7 7XX.Company registration number: 05796994. Registered in England & Wales.

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RT-TEM-164-e V5.3

Confirmation of consent (To be completed by a health professional when the patient arrives for CT or first treatment)

I confirm that I have held appropriate dialogue with the patient, and they wish to proceed with the treatment course and in my opinion they fully understand the benefits and risks.

Additional comments/discussion held:

Signed: Date:

Print name: Job title:

Withdrawal of consent

I wish to withdraw my consent to radiotherapy.

Signed: Date:

Print name:

Was a copy of this document (3 pages) accepted by the patient? Yes No

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Clinician signature

Signed: Date:

Print name: GMC number:

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Patient’s signature

I agree to undergo radiotherapy. I understand the procedure(s) to be performed and I am aware of the potential side-effects arising from this treatment.

If female – I can confirm that I am not pregnant.

I agree to outcome data of my treatment being collected and used for national benchmarking.

I understand that you cannot guarantee a particular staff member will perform the procedure(s).

All staff performing the procedure(s) are adequately trained and qualified.

During your treatment there may be students and members of staff who are not directly involved in delivering your treatment in the clinical environment.

I understand I have the right to withdraw my consent at any time.

I consent to GenesisCare obtaining previous records as required.

Signed: Date:

Print name:

If you have any queries or worries relating to your radiotherapy, then please call the radiographers or consultant before the date you are due to attend for your appointment.

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