Chemotherapy Consent Forms for Solid Tumours

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

PICC consent

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.

Abemaciclib consent
Abraxane consent
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
Afatinib consent
Alectinib consent
Atezolizumab consent
Atezolizumab + Abraxane consent
Atezolizumab, Bevacizumab, Paclitaxel & Carboplatin consent
Avelumab consent
Axitinib consent 
BEP consent
Bevacizumab consent 
Bevacizumab, Paclitaxel & Carboplatin consent
Brigatinib consent
Cabazitaxel consent
Cabozantinib consent
Caelyx (Liposomal Doxorubicin) consent
Caelyx & Carboplatin consent
CAP consent
Capecitabine consent
Capecitabine & Docetaxel consent
Capecitabine & Mitomycin C consent
Capecitabine & Streptozocin consent
Capecitabine & Temozolomide consent
Carboplatin consent
Carboplatin & Capecitabine consent
Carboplatin & Etoposide consent
Carboplatin & 5FU consent
CAV consent 
Cemiplimab consent
Ceritinib consent
Cetuximab, Carboplatin & 5FU consent
Cetuximab, Cisplatin & 5FU consent
Cetuximab & Irinotecan Mod de Gramont consent
Cetuximab & Oxaliplatin Modified de Gramont
Cisplatin consent 
Cisplatin & Capecitabine consent
Cisplatin & Etoposide consent
Cisplatin & 5FU consent
Crizotinib consent
Cyclophosphamide oral consent
Dabrafenib & Trametinib consent
Dacarbazine for melanoma consent
Docetaxel consent
Docetaxel & Carboplatin consent
Docetaxel & Cyclophosphamide consent
Docetaxel & Nintedanib consent
Docetaxel, Pertuzumab & Trastuzumab (metastatic breast cancer) consent
Doxorubicin consent
Durvalumab consent
EAP-mitotane consent
EC consent
EC – Docetaxel consent
ECX consent
E-Carbo-X consent
Encorafenib & Binimetinib consent
EOX consent
Epirubicin consent
Eribulin consent
Erlotinib consent
Everolimus consent
Everolimus & Lenvatinib consent
FCiSt consent
FLOT consent
Folfirinox consent
Folfoxiri consent
Gefitinib consent
Gemcitabine consent
Gemcitabine & Capecitabine consent
Gemcitabine Carboplatin consent
Gemcitabine & Cisplatin consent
Gemcitabine & Docetaxel consent
Ifosfamide consent
Imatinib consent
Ipilimumab consent
Ipilimumab & Nivolumab consent
Irinotecan consent
Irinotecan + Capecitabine consent
Irinotecan Modified de Gramont consent
Kadcyla (Trastuzumab emtansine) consent
Lenvatinib (Lenvima) consent
Lomustine consent
Lorlatinib consent
Mitoxantrone & Prednisolone consent
Modified de Gramont consent
Niraparib consent
Nivolumab consent
Olaparib consent
Osimertinib 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 
Palbociclib consent
Panitumumab & Irinotecan Mod de Gramont (Folfiri) consent
Panitumumab & Oxaliplatin Mod de Gramont (Folfox) consent
Pazopanib consent
PCV  Consent
Pembrolizumab consent
Pembrolizumab, Paclitaxel & Carboplatin consent
Pembrolizumab, Pemetrexed & Carboplatin consent
Pembrolizumab, Pemetrexed & Cisplatin consent
Pemetrexed & Carboplatin consent
Pemetrexed & Cisplatin consent
Pemetrexed consent
Raltitrexed consent
Raltitrexed & Oxaliplatin consent
Regorafenib consent
Ribociclib consent
Rucaparib consent
Sorafenib consent
Sunitinib consent
Temozolomide consent
TPF consent
TCarboF (TPF with carbo substitution) consent
Tivozanib consent
Topotecan consent
Topotecan & Cisplatin consent
Trastuzumab (Herceptin or Ontruzant) consent
Trifluridine & Tipiracil (Lonsurf) consent
Vinorelbine 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.