Chemotherapy Consent Form

Please complete the form below to provide consent for chemotherapy treatment.

Name *

First

Last

Today's Date *

Email *

I understand that my pet has been diagnosed with cancer. I have consulted with the oncologist at Private Veterinary Specialties LLC and have been informed of the potential for this type of cancer to progress locally and metastasize (spread) to distant sites. *

I have read and understand.

I have been informed of the treatment options for my pet’s cancer. I understand that the outcome of treatment depends on the specific type of cancer, how advanced the cancer is at the time of diagnosis and treatment options I elect. I realize that a prognosis is merely an informed opinion, and in no way guarantees a specific survival time/duration. In addition, my pet’s prognosis may become better or worse, depending on tumor progression, response to treatment, and other medical conditions of my pet. *

I have read and understand.

I understand that chemotherapy, either alone or in combination with other treatments such as surgery or radiation therapy, has the potential to be an effective treatment option to address my pet’s cancer. I understand that chemotherapy, like any other cancer therapy, offers no guarantee of effectiveness and that the use of chemotherapy drugs in companion animals is considered “off-label use.” No promises of any kind about the outcome of my pet’s therapy are being made or implied. *

I have read and understand.

I understand that while there is potential benefit, any type of cancer therapy has the potential for severe and life-threatening toxicity. The potential complications associated with chemotherapy include but are not limited to a low white blood cell count, infertility, fever, infection, and gastrointestinal side effects (vomiting, diarrhea, anorexia). Less common complications included allergic reactions, heart damage, irritation to the urinary bladder, tissue damage secondary to drug extravasation or death. *

I have read and understand.

I realize that every effort will be made to prevent, identify, and control any adverse effects my pet may experience. *

I have read and understand.

I have been advised that my pet may have some chemotherapy in his or her urine, feces and/or saliva following chemotherapy treatments. I am aware that I should wear gloves if it is necessary to clean up after my pet and that pregnant women & children should not clean up pet excrement or handle any of his/ her chemotherapeutic medications. I have also been advised that I should wear gloves when handling my pet’s chemotherapeutic medications to minimize my contact with these drugs. *

I have read and understand.

I have read the above statement of consent, and have been given the opportunity to fully discuss it with my veterinarian. I have made the informed decision to pursue chemotherapy treatment for my pet. I retain the right to discontinue therapy at any time, at my discretion. I understand that a signed consent is required prior to the initiation of chemotherapy treatment. *

I have read and understand.

Message