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.
PICC Consent Form
A to Z of Chemotherapy Consent Forms
These consent forms are for solid tumour chemotherapy only, and are NOT to be used for chemo-radiotherapy regimens.
See also comments below the consent forms.
Abraxane (nab-paclitaxel) & Gemcitabine consent
Accelerated EC – accelerated paclitaxel consent
Accelerated EC – Docetaxel consent
Pertuzumab & Trastuzumab (neo-adjuvant or adjuvant) consent
Accelerated EC – Paclitaxel & carboplatin consent
Accelerated MVAC consent
Atezolizumab + Abraxane consent
Atezolizumab, Bevacizumab, Paclitaxel & Carboplatin consent
Bevacizumab, Paclitaxel & Carboplatin consent
Caelyx (Liposomal Doxorubicin) consent
Caelyx & Carboplatin consent
Capecitabine & Docetaxel consent
Capecitabine & Mitomycin C consent
Capecitabine & Streptozocin consent
Capecitabine & Temozolomide consent
Carboplatin & Capecitabine consent
Carboplatin & Etoposide consent
Carboplatin & 5FU consent
Cetuximab, Carboplatin & 5FU consent
Cetuximab, Cisplatin & 5FU consent
Cetuximab & Irinotecan Mod de Gramont consent
Cetuximab & Oxaliplatin Modified de Gramont
Cisplatin & Capecitabine consent
Cisplatin & Etoposide consent
Cisplatin & 5FU consent
Cyclophosphamide oral consent
Dabrafenib & Trametinib consent
Dacarbazine for melanoma consent
Docetaxel & Carboplatin consent
Docetaxel & Cyclophosphamide consent
Docetaxel & Nintedanib consent
Docetaxel, Pertuzumab & Trastuzumab (metastatic breast cancer) consent
EC – Docetaxel consent
Encorafenib & Binimetinib consent
Everolimus & Lenvatinib consent
Gemcitabine & Capecitabine consent
Gemcitabine Carboplatin consent
Gemcitabine & Cisplatin consent
Gemcitabine & Docetaxel consent
Ipilimumab & Nivolumab consent
Irinotecan + Capecitabine consent
Irinotecan Modified de Gramont consent
Kadcyla (Trastuzumab emtansine) consent
Lenvatinib (Lenvima) consent
Mitoxantrone & Prednisolone consent
Modified de Gramont consent
Oxaliplatin + Capecitabine consent
Oxaliplatin Modified de Gramont consent
Paclitaxel (weekly) consent
Paclitaxel & Carboplatin consent
Paclitaxel, Carboplatin & Epirubicin (TEC) consent
Paclitaxel & Cisplatin consent
Paclitaxel & Gemcitabine consent
Panitumumab & Irinotecan Mod de Gramont (Folfiri) consent
Panitumumab & Oxaliplatin Mod de Gramont (Folfox) consent
Pembrolizumab, Paclitaxel & Carboplatin consent
Pembrolizumab, Pemetrexed & Carboplatin consent
Pembrolizumab, Pemetrexed & Cisplatin consent
Pemetrexed & Carboplatin consent
Pemetrexed & Cisplatin consent
Raltitrexed & Oxaliplatin consent
TCarboF (TPF with carbo substitution) consent
Topotecan & Cisplatin consent
Trastuzumab (Herceptin or Ontruzant) consent
Trifluridine & Tipiracil (Lonsurf) consent
Vinorelbine & Carboplatin consent
Vinorelbine & Cisplatin consent
Weekly 5FU & Folinic acid consent
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 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.
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.