Medical Records Collection Form

[EN] Physician Referral Consent Form

Medical Records Collection Consent Form

HIPAA/GDPR Authorization

Your Legal Name

Your Email Address

Your Phone Number

Your Date of Birth (MM/DD/YYYY)

Cancer Center Where You Get Treated

Your Oncologist Name

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.