Radiation Therapy Consent Form

The Radiation Therapy Consent Form provides comprehensive informed consent documentation for patients undergoing therapeutic ionizing radiation. This template addresses the full spectrum of radiation treatment modalities including external beam radiation therapy (EBRT), intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), stereotactic body radiation therapy (SBRT), stereotactic radiosurgery (SRS), proton beam therapy, and brachytherapy. The form captures the radiation oncologist's explanation of the treatment site, prescribed dose in Gray (Gy), fractionation schedule, and total number of planned treatment sessions.

The consent includes detailed sections for both acute and late radiation toxicities specific to the treatment site. For example, head and neck irradiation includes mucositis, xerostomia, dysphagia, and hypothyroidism risk; thoracic radiation includes pneumonitis and esophagitis; pelvic radiation includes enteritis, cystitis, and gonadal toxicity. The form documents the discussion of fertility preservation options for patients of reproductive age, including sperm banking, oocyte cryopreservation, and ovarian transposition where applicable. Concurrent chemoradiation risks are addressed when systemic therapy is planned alongside radiation.

Simulation and treatment planning consent is included as a dedicated section covering CT simulation, immobilization device fitting, skin tattoo markings for alignment, and the use of image-guided radiation therapy (IGRT) for daily verification. Patients acknowledge the importance of maintaining the treatment position, reporting any changes in condition during the treatment course, and attending all scheduled fractions. Both patient and radiation oncologist signatures with date stamps create a compliant medicolegal record meeting ACR, ASTRO, and state radiation safety regulatory requirements.