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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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