Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Radiation Therapy Consent Form
Your information
Patient Name *
Cancer Diagnosis & Treatment Site
Radiation Modality
Prescribed Dose & Fractionation
Acute Toxicity Risks Acknowledged
Late Toxicity Risks Acknowledged
Fertility Preservation Discussion
Additional details
Concurrent Chemotherapy Risks
Simulation & Planning Consent
Your practice's consent wording goes here.
Signature
Date
Skin Marking Consent
Your practice's consent wording goes here.
Signature
Date
Treatment Compliance Acknowledgment
Emergency Contact
Patient Signature
Date
Radiation Oncologist Signature
Date
Radiation Therapy Consent Form template from formisoft.com. formisoft.com/intake-templates/radiation-therapy-consent