Medical Records Collection Form - Massive Bio

Medical Records Collection Consent Form

HIPAA/GDPR Authorization

Please select below and tell us who you are.

[EN] Consent Form Manual - For Legal Guardians

Patient's Legal First Name

Patient's Legal Last Name

Patient’s Email Address

Patient’s Phone Number

Patient’s Date of Birth (MM/DD/YYYY)

Patient's Oncologist Name

Your Full Name

Relation to Patient

By agreeing, you accept the terms and conditions, and the privacy policy, and you authorize Massive Bio to process your information under the applicable privacy framework (HIPAA, GDPR, PIPEDA). If your consent document is available in multiple languages, both the English legal version and the translated version will be sent to you for your records.

By filling out this form, you're consenting only to release your medical records. You're not agreeing to participate in clinical trials yet.

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