CONSENT FOR RADIATION THERAPY TO PARTIAL BREAST ONLY (ENGLISH), #572132 Hartford Hospital Consent Fo 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'PATIENT NAME' field. Ensure that you print your name clearly for accurate identification.
3. Fill in your medical record number (MR#) in the designated space. This helps maintain your medical records accurately.
4. Authorize your physician by writing their name in the provided space, confirming who will administer the treatment.
5. Indicate which breast will receive treatment by checking either 'Left Breast' or 'Right Breast'.
6. Read through the consent details carefully, ensuring you understand the potential benefits and risks associated with accelerated partial breast irradiation (APBI).
7. Initial where indicated, especially if you are female and confirm that you are not pregnant.
8. Sign and date the form at the bottom to finalize your consent.

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