Dupuytren’s disease, Ledderhose disease, Plantar fasciitis, Achilles tendonitisRadiotherapy patient consent to treatment

Patient information

GenesisCare number:

Last name: First name:

Date of birth: Sex: Male: Female:

Address:

Is English the patient’s first language? Yes No

Are there any special requirements e.g. translation services? Please specify Yes No

Course of radiotherapy treatment to

Dupuytren’s disease Left hand Right hand Left foot Right foot

Ledderhose disease Left hand Right hand Left foot Right foot

Plantar fasciitis Left hand Right hand Left foot Right foot

Achilles tendonitis Left hand Right hand Left foot Right foot

The intended benefits

Reduce the likelihood of growth of nodules/cords, reduce the chance of contracture, reduce the need for surgery:

Yes No

Prevent recurrence of disease: Yes No

Reduce pain: Yes No

Other: Please specify Yes No

Common short-term side effects

Dupuytren’s disease/Ledderhose disease

• Skin redness, soreness and dryness • Temporary acute pain in treated region

Plantar fasciitis/Achilles Tendonitis

• Minor skin reddening and soreness

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Any other comments/discussion

Previous treatmentIf this treatment overlaps previous radiotherapy treatment or is close to previous radiotherapy treatment (so there is risk of overlap), then common and uncommon side-effects may be more likely.

It may be required under some circumstances to obtain previous records from other healthcare providers to support the intended treatment.

Clinician signature

Signed: Date:

Print name: GMC number:

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To the patient

You have discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment).

You will be supplied with verbal information and a radiotherapy care plan pack which contains printed information.

There are extra procedures which may be necessary during the initial part of your pathway:

• Photographs for identification and treatment delivery• Temporary mark-up of effected area

Other procedure, please specify:

Uncommon long-term side effects and possible worsening effects

Dupuytren’s disease/Ledderhose disease

• Permanent skin changes (texture and colour)• Telangiectasia (formation of small but prominent blood vessels)• Subcutaneous fibrosis (thickening of tissue)• Skin breakdown (oozing and scab formation)

Plantar fasciitis/Achilles Tendonitis

• Not applicable

Rare long-term side effects

Dupuytren’s disease/Ledderhose disease

• Theoretical risk of cancer – individual risk to be discussed with consultant

Plantar fasciitis/Achilles Tendonitis

• Theoretical risk of cancer – individual risk to be discussed with consultant

GenesisCare is a trading name of Genesis Cancer Care UK Limited. Registered Office: Wilson House, Waterberry Drive, Waterlooville, Hampshire PO7 7XX.Company registration number: 05796994. Registered in England & Wales.

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RT-TEM-207-e V4.3

Confirmation of consent (To be completed by a health professional when the patient arrives for CT or first treatment)

I confirm that I have held appropriate dialogue with the patient, and they wish to proceed with the treatment course and in my opinion they fully understand the benefits and risks.

Additional comments/discussion held:

Signed: Date:

Print name: Job title:

Withdrawal of consent

I wish to withdraw my consent to radiotherapy.

Signed: Date:

Print name:

Was a copy of this document (3 pages) accepted by the patient? Yes No

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Patient’s signature

I agree to undergo radiotherapy. I understand the procedure(s) to be performed and I am aware of the potential side-effects arising from this treatment.

If female – I can confirm that I am not pregnant.

I agree to outcome data of my treatment being collected and used for national benchmarking.

I understand that you cannot guarantee a particular staff member will perform the procedure(s).

All staff performing the procedure(s) are adequately trained and qualified.

During your treatment there may be students and members of staff who are not directly involved in delivering your treatment in the clinical environment.

I understand I have the right to withdraw my consent at any time.

I consent to GenesisCare obtaining previous records as required.

Signed: Date:

Print name:

If you have any queries or worries relating to your radiotherapy, then please call the radiographers or consultant before the date you are due to attend for your appointment.

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