Chemotherapy Administration Authorization and Consent form

Client Information

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Patient Information

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I, the undersigned owner or authorized agent of the owner responsible for seeking veterinary care for the pet identified above, understand that my pet has been diagnosed with cancer. After consultation with the oncologists of Veterinary Specialists of the Rockies, it has been determined that chemotherapy, either alone or in combination with other treatments, has the potential to help with my pet’s diagnosis.

Based upon all pertinent information provided about my pet’s health, the oncologists at Veterinary Specialists of the Rockies may be able to formulate a prognosis. Recommendations and pertinent information regarding statistical outcomes have been provided and explained, but in no way imply or assure any given outcomes. I understand that this information is based on an informed opinion, clinical experience and advanced training on the part of my pet’s oncologist, and in no way guarantees a period of tumor control or survival. I have also been informed of the type of cancer/diagnosis for my pet and that there is a potential for cancer to progress locally and/or metastasize (spread) to distant sites. I acknowledge that the efficacy of chemotherapy and the outcome of my pet’s therapy cannot be guaranteed. I also understand this can also depend on the type and status of my pet’s cancer, as well as my pet’s overall health status.

My oncologist has also discussed that the use of chemotherapy maintains a potential for severe, and rare life threatening complications. The potential complications associated with chemotherapy include but are not limited to a low white blood cell count, infertility, fever, infection, and gastrointestinal side effects (vomiting, diarrhea, anorexia). Less common complications include allergic reaction, heart disease, irritation to the urinary bladder, tissue damage secondary to drug extravasation or death. Every effort will be made to identify, control and prevent these complications. I have also been informed that most chemotherapy drugs used in veterinary patients are human therapeutic medications and have not been approved by the FDA for use in these species.

I acknowledge that there are inherent risks to humans and my own safety while my pet is actively receiving chemotherapy and I will abide by recommended safety precautions as instructed by my pet’s oncologist. I have been advised that my pet may have some chemotherapy in his or her urine, feces, vomit, and/or saliva following chemotherapy treatments. I am aware that I should wear gloves if it is necessary to clean up after my pet. I understand that pregnant women, children and immunocompromised individuals should not clean up pet excrement or bodily fluids or handle any of my pet’s chemotherapeutic medications. I have been advised that I should wear gloves when handling my pet’s chemotherapeutic medications to minimize any contact with these drugs and will follow all label instructions for medication administration. I acknowledge that Veterinary Specialists of the Rockies cannot be held liable for the potential risks or hazards to my own safety or to other humans.

I have read and understand this statement of consent. I have been given the opportunity to fully discuss this with my pet’s oncologist and I have made the informed decision to pursue chemotherapy for my pet. I acknowledge that any changes to the protocol will be discussed with me prior, and I retain the right to discontinue therapy at any time at my discretion. I will abide by and understand the chemotherapy risks and safety recommendations. I understand that a signed consent form is required prior to initiation of chemotherapy treatment.

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