CONSENT FOR RADIATION THERAPY TO THE CHEST/UPPER BACK AREA, #577136. Hartford Hospital Consent Forms 2026

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The document is a consent form for radiation therapy to the chest/upper back area, outlining the patient's acknowledgment of the treatment's potential benefits, risks, and alternatives. It details the informed consent process, including possible side effects and complications associated with radiation therapy. The patient agrees to the treatment under the supervision of their physician and authorizes documentation of their image for medical purposes. Additionally, it includes specific considerations for female patients regarding pregnancy.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the 'PATIENT NAME' field. Ensure that you print your name clearly for accurate identification.
Fill in your medical record number (MR#) in the designated space to help the hospital track your treatment history.
In the section for 'Proposed Radiation Oncology Treatment site', specify the exact area where treatment will be administered, ensuring clarity for medical staff.
Read through the consent statements carefully. You may need to initial next to specific acknowledgments regarding potential risks and benefits of radiation therapy.
If applicable, complete the section for females regarding pregnancy status by providing initials as required.
Finally, sign and date the form at the bottom, confirming your understanding and consent for treatment.

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