Date of Birth

Age plays a role in which trials work most effectively.

What is your Cancer type?

Determining your type of cancer helps us narrow down your trial options from thousands to dozens.

Email Address

We will follow up with you and keep you updated on our process.

Phone Number

If you prefer texts or phone calls, we can contact you there as well.

Medical Records Collection Consent

(HIPAA/GDPR Authorization)

• Access quality care. Your consent is the first step in clinical trial matching.
• No hidden intentions. We don't sell your data to third parties. Your information is used only to determine clinical trial eligibility.
• Commitment-free. By filling out this form, you're consenting only to release your medical records. You're not agreeing to participate in clinical trials yet.
• Risk-free. You can opt out of the process at anytime. We understand you might change your mind later.
• Data protection. We ensure the safety and privacy of your protected health information.
• A dedicated patient relations coordinator will call you to discuss details further.

Thank you for all information.

After reviewing your information, we will contact you in soon