All consent forms on this website are for the use of St Luke’s Cancer Alliance staff only.
For those who do not work within St Luke’s Cancer Alliance:
Use of this site and any information on it is at your own risk. We do not accept responsibility for the use of any information that may be set out on the website. You assume full responsibility for the use of the information.
Please note that the consent forms below are not tumour-specific; one consent form may be used to consent patients for more than one St Luke’s Alliance chemotherapy protocol which uses the same combination of chemotherapy.
These consent forms should act as an aide-memoire to health professionals and patients, by providing a check-list of the kind of information which patients should be offered, and by enabling the patient to have a written record of the main points discussed.
The relevant Macmillan/CRUK leaflet(s) should also be provided to each patient before consent. In no way, however, should written information given to the patient be regarded as a substitute for face-to-face discussions with the patient.
A to Z of Haematology Chemotherapy Consent Forms
Arsenic with Tretinoin consent
Cytarabine subcut consent
High dose Cytarabine consent
Cyclophosphamide weekly consent
Ixazomib, Lenalidomide & Dex consent
Panobinostat and bortezomib consent
MPD / MDS
Lymphomas & CLL
High dose Methylprednisolone consent
High dose MTX and Cytarabine (Ferreri) consent
High dose MTX for CNS prophylaxis consent
R-High dose methylprednisolone consent
Rituximab IV consent
Rituximab Subcutaneous consent
When NOT to use these consent forms
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, 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 do so under a Lasting Power of Attorney or as a court appointed deputy.