Hello! I'm Fiona,
I will ask you some questions in minutes. Are you
ready to go?
Are You A Cancer Patient?
Are You A Caregiver or Relative Of A Cancer Patient?
What is your name?
This information helps us contact you for further discussion.
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.
We will follow up with you and keep you updated on our process.
If you prefer texts or phone calls, we can contact you there as
Your physician’s first and last name
Please provide the following information, which we require in order to
obtain your medical records.
Your physician’s phone number
I confirm this Synergy AI HIPAA/GDPR release form
Thank you for all information.
After reviewing your information, we will contact you in soon
Please check your
password or email.