Case Study Submission Form

NOTE: This form is not intended for dissemination of confidential patient information and is used for educational purposes only. Please do not disclose any identifying patient information in this form.

If you wish to use a paper form, you can download one here.

Please complete the following fields to submit an invasive breast cancer case study

*Required

Submitted By

Patient Information

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Physician release of de-identified medical information to Exact Sciences Corporation


This release applies to the information entered above (“Case Study Information”) by me or at my direction.

By my electronic signature below as of the date of this submission, I authorize Exact Sciences Corporation to use, publish and copy this Case Study Information, in whole or in part, for illustration, trade, advertising, marketing and promotion of Exact Sciences' products and services in any medium, and without any obligation to me whatsoever, including monetary compensation. I represent that the Case Study Information does not include any patient name, address, phone number or social security number, or any other identifying number, clinical characteristic (e.g., HER2 status) or code unique to this patient. I understand that Exact Sciences does not have to return any Case Study Information to me.

My authorization and release of the Case Study Information does not constitute an endorsement, approval or recommendation by me, or any institution with which I am affiliated, of Oncotype or any other Exact Sciences product or service.

I have read this release, and have had the opportunity both to obtain legal advice to interpret its provisions, and to ask Exact Sciences questions about it. Any such questions have been answered to my satisfaction.

I understand that my electronic signature below shall have the same force and effect as an ink signature.

NOTE: This form is not intended for dissemination of confidential patient information and is used for educational purposes only. Please do not disclose any identifying patient information in this form.

Please complete the following fields to submit a prostate cancer case study

*Required

Submitted By

Patient Information

Pre-GPS assay workup

GPS Results

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Post-GPS assay report action

continue to the release form below

Physician release of de-identified medical information to Exact Sciences Corporation


This release applies to the information entered above (“Case Study Information”) by me or at my direction.

By my electronic signature below as of the date of this submission, I authorize Exact Sciences Corporation to use, publish and copy this Case Study Information, in whole or in part, for illustration, trade, advertising, marketing and promotion of Exact Sciences' products and services in any medium, and without any obligation to me whatsoever, including monetary compensation. I represent that the Case Study Information does not include any patient name, address, phone number or social security number, or any other identifying number, clinical characteristic (e.g., HER2 status) or code unique to this patient. I understand that Exact Sciences does not have to return any Case Study Information to me.

My authorization and release of the Case Study Information does not constitute an endorsement, approval or recommendation by me, or any institution with which I am affiliated, of Oncotype DX® tests or any other Exact Sciences product or service.

I have read this release, and have had the opportunity both to obtain legal advice to interpret its provisions, and to ask Exact Sciences questions about it. Any such questions have been answered to my satisfaction.

I understand that my electronic signature below shall have the same force and effect as an ink signature.

NOTE: This form is not intended for dissemination of confidential patient information and is used for educational purposes only. Please do not disclose any identifying patient information in this form.

If you wish to use a paper form, you can download one here.

Please complete the following fields to submit a colon cancer case study

*Required

Submitted By

Patient Information

continue to the release form below

Physician release of de-identified medical information to Exact Sciences Corporation


This release applies to the information entered above (“Case Study Information”) by me or at my direction.

By my electronic signature below as of the date of this submission, I authorize Exact Sciences Corporation to use, publish and copy this Case Study Information, in whole or in part, for illustration, trade, advertising, marketing and promotion of Exact Sciences' products and services in any medium, and without any obligation to me whatsoever, including monetary compensation. I represent that the Case Study Information does not include any patient name, address, phone number or social security number, or any other identifying number, clinical characteristic (e.g., HER2 status) or code unique to this patient. I understand that Exact Sciences does not have to return any Case Study Information to me.

My authorization and release of the Case Study Information does not constitute an endorsement, approval or recommendation by me, or any institution with which I am affiliated, of Oncotype or any other Exact Sciences product or service.

I have read this release, and have had the opportunity both to obtain legal advice to interpret its provisions, and to ask Exact Sciences questions about it. Any such questions have been answered to my satisfaction.

I understand that my electronic signature below shall have the same force and effect as an ink signature.

NOTE: This form is not intended for dissemination of confidential patient information and is used for educational purposes only. Please do not disclose any identifying patient information in this form.

If you wish to use a paper form, you can download one here.

Please complete the following fields to submit a DCIS case study

*Required

Submitted By

Patient Information

%
%

continue to the release form below

Physician release of de-identified medical information to Exact Sciences Corporation


This release applies to the information entered above (“Case Study Information”) by me or at my direction.

By my electronic signature below as of the date of this submission, I authorize Exact Sciences Corporation to use, publish and copy this Case Study Information, in whole or in part, for illustration, trade, advertising, marketing and promotion of Exact Sciences' products and services in any medium, and without any obligation to me whatsoever, including monetary compensation. I represent that the Case Study Information does not include any patient name, address, phone number or social security number, or any other identifying number, clinical characteristic (e.g., HER2 status) or code unique to this patient. I understand that Exact Sciences does not have to return any Case Study Information to me.

My authorization and release of the Case Study Information does not constitute an endorsement, approval or recommendation by me, or any institution with which I am affiliated, of Oncotype or any other Exact Sciences product or service.

I have read this release, and have had the opportunity both to obtain legal advice to interpret its provisions, and to ask Exact Sciences questions about it. Any such questions have been answered to my satisfaction.

I understand that my electronic signature below shall have the same force and effect as an ink signature.

NOTE: Exact Sciences will not claim that you endorse the Oncotype DX Breast Recurrence Score® test because you have submitted a case. Please do not provide a patient’s name, date of birth, or any information that could identify the patient. If you confirm below that you have obtained the patient’s consent to submit this case, and Exact Sciences shares the case with other professionals, it will be attributed to you and will mention your city and country of practice. If you have not obtained the patient’s consent, the case will not be attributed to you and will mention only your country to ensure that the clinical information is anonymised.

Please complete the following fields to submit an invasive breast cancer case study

*Required

Submitted By

Patient Information

%
%
%

continue to the release form below

Terms of Case Submission

I authorise Exact Sciences Corporation and its subsidiaries (‘Exact Sciences’) to use, publish and copy the case information, including my name and location (all together, the ‘Case Submission’) for any legitimate purpose, including promotion of the Oncotype DX Breast Recurrence Score® test, without any remuneration to me. I confirm that the Case Submission is accurate information about a real case. If the ‘Patient Consent’ field above is completed with ‘yes’, I certify that I have obtained that consent after informing the patient that her/his age and pathology information may be associated with my name, city, and country, and that this information together may be used for educational and promotional purposes by Exact Sciences.

By signing and submitting the case below, I AGREE to the above-defined terms.

NOTE: This form is not intended for dissemination of confidential patient information and is used for educational purposes only. Please do not disclose any identifying patient information in this form.

If you wish to use a paper form, you can download one here.

Please complete the following fields to submit a lung cancer case study

*Required

Submitted By

Patient Clinical Parameters

Pre-Oncotype MAP Testing and Treatment

Treatment and Progression Status Prior to Oncotype MAP testing

Oncotype MAP Tissue Testing and Clinical Status

Follow-Up

Please attach any de-identified pre-/post-treatment images, if available
×
jpg, png, doc, docx, pdf are accepted and limited 10MB

continue to the release form below

Physician release of de-identified medical information to Exact Sciences Corporation


This release applies to the information entered above (“Case Study Information”) by me or at my direction.

By my electronic signature below as of the date of this submission, I authorize Exact Sciences Corporation to use, publish and copy this Case Study Information, in whole or in part, for illustration, trade, advertising, marketing and promotion of Exact Sciences' products and services in any medium, and without any obligation to me whatsoever, including monetary compensation. I represent that the Case Study Information does not include any patient name, address, phone number or social security number, or any other identifying number, clinical characteristic or code unique to this patient. I understand that Exact Sciences does not have to return any Case Study Information to me.

My authorization and release of the Case Study Information does not constitute an endorsement, approval or recommendation by me, or any institution with which I am affiliated, of the Oncotype MAP Pan-Cancer Tissue Test or any other Exact Sciences product or service.

I have read this release, and have had the opportunity both to obtain legal advice to interpret its provisions, and to ask Exact Sciences questions about it. Any such questions have been answered to my satisfaction.