Chemotherapy Safety Awareness Sheet for Clients Client InformationClient Name Address Street Address City State / Province / Region ZIP / Postal Code Phone Number Patient InformationPatient Name Species Breed Sex Color Weight Is your pet spayed/neutered? Yes Date MM slash DD slash YYYY Chemotherapy agents administered to human patients are known to cause birth defects, chromosome changes, and/or carcinogenic effects. Because of these side effects, concern has been raised regarding the potential hazard to those who administer chemotherapeutic agents to their pets and every precaution should be taken at home. PREGNANT WOMEN, YOUNG CHILDREN and the IMMUNOCOMPROMISED are potentially at a greater risk and therefore should not handle or administer chemotherapeutic agents or be exposed to pet wastes or bodily fluids. Due to the potential problems associated with chemotherapeutic agents, we advise caution in their use and have the following recommendations: Wear the supplied gloves when administering medication to my pet Wash my hands before and after administration of the medication DO NOT crush or break pills Flush skin with water for 15 minutes if skin comes in contact with the chemotherapeutic drug and contact my physician Wear gloves when in contact with animal waste (litter boxes, ‘accidents’, cleaning up vomit, etc.). Clean up excrement daily. Flush wastes down the toilet or double bag them to dispose of them in household garbage Provide plenty of fresh water and multiple opportunities to eliminate Handle soiled linen/clothing only with gloves, use bleach to wash and wash separately from other laundry We recommend bringing used pill vials/syringes, gloves and unused drug back to the clinic for disposal Advise my personal physician and veterinarian of any problems I have read the above instructions, will comply to the recommendations and have received a copy.Owner/Agent Signature(Required)NameThis field is for validation purposes and should be left unchanged. Δ
