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Hep C Treatment Consent Form

Hepatitis C Treatment Consent Form

Instructions: This document is designed to provide you with information about the treatment options available for Hepatitis C. It includes details about the benefits and risks associated with the medications. Please read this document carefully and ask any questions before consenting to treatment.

Patient Name:(Required)
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Hepatitis C Overview: Hepatitis C is a viral infection that primarily affects the liver. If left untreated, it can lead to serious liver damage, including cirrhosis and liver cancer. The goal of treatment is to eradicate the virus from your body, improving liver health and reducing the risk of complications.


Treatment Options: There are several direct-acting antiviral medications used to treat Hepatitis C. The following three medications are commonly prescribed:

Sofosbuvir (Sovaldi) or Sofosbuvir/Velpatasvir (Epclusa)

  • • Benefits: Highly effective in clearing the virus, usually with a 95% cure rate; well-tolerated.
  • • Risks/Side Effects: Headache, fatigue, nausea, insomnia, and potential interaction with other medications.

Ledipasvir/Sofosbuvir (Harvoni)

  • • Benefits: Combines two antiviral agents for increased effectiveness; also has a high cure rate.
  • • Risks/Side Effects: Similar to Sofosbuvir, with additional potential for dizziness and elevated liver enzymes.

Glecaprevir/Pibrentasvir (Mavyret)

  • • Benefits: Effective for all genotypes of Hepatitis C; shorter treatment duration may be possible (8-12 weeks).
  • • Risks/Side Effects: Fatigue, headache, diarrhea, and potential interactions with certain other medications.

Benefits of Treatment:

Cure Rate: Most patients achieve sustained virologic response (SVR), meaning the virus is no longer detectable in the blood.

Liver Health: Reduces the risk of liver cirrhosis, liver failure, and hepatocellular carcinoma (liver cancer).

Quality of Life: Improvement in overall health and well-being after successful treatment.

Preventing Transmission: Reduces the risk of transmitting the virus to others.

Risks of Treatment:

Side Effects: As noted above, treatment may cause mild to moderate side effects, which typically resolve after completion of therapy.

Drug Interactions: Some medications may interact with Hepatitis C treatments, which could either reduce effectiveness or increase side effects.

Treatment Resistance: In rare cases, the virus may develop resistance to treatment, making it less effective.

Withdrawal Effects: Some patients may experience withdrawal symptoms from medications if they stop treatment prematurely.

Patient Rights:

You have the right to ask questions about your treatment.

You have the right to refuse treatment or withdraw consent at any time without affecting your future care.

Consent: By signing below, you acknowledge that you have read and understood the information provided above regarding the treatment for Hepatitis C. You have had the opportunity to ask questions and discuss your concerns with your healthcare provider.

Clear Signature
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