I, the undersigned, *

(first name and family name) 

1. *

  • Confirm that I have read the Informed Consent Form (Last update: 25 April 2018 – V01) (or had it read to me) concerning the Test(s) that I have selected (or that I might select in the future) and that the Test procedures have been explained to me by my doctor during the informed consent process;

  • Confirm that I have had the opportunity to ask questions about the selected Tests, and obtained satisfactory answers to my questions;

  • Confirm that I have had the time to think about accepting the selected Tests;

  • Understand that I authorize the processing of and access to my Personal Data, including Health Data, to OncoDNA, BIO.be, IPG and authorized recipients mentioned in the present Informed Consent Form;

  • Authorize the processing by OncoDNA of my Health Data, as identified in this Informed Consent Form, without the supervision of a health professional, for the purpose of performing the selected Tests and generating the Reports;

  • Accept to have the selected Tests performed on my Samples.

2. *

In addition, I authorize the collection and processing of my Personal Data (including Health Data) by OncoDNA for the purpose of its integration in the existing OncoDNA database, so that OncoDNA may continue to improve upon its service delivery and provide more accurate and tailor-made services and Reports to other (future) cancer patients as explained in this Informed Consent Form.

3. *

Confirm that I have received the opportunity to refuse that part of my Remaining Samples is used by OncoDNA or third parties for purely scientific research to allow OncoDNA to continue to improve the accuracy of its tailor-made services in the field of cancer treatment and reports to other (future) cancer patients as explained in this Informed Consent Form

WITNESS

A WITNESS IS ONLY REQUIRED IF THE SUBJECT OR HIS/HER LEGAL REPRESENTATIVE CANNOT READ, IS UNDER AGE OR INCAPACITATED

I confirm that I have no link with OncoDNA, that I have been present during the entire informed consent process and that I have read the information relating to the Tests. I confirm that the information in this Informed Consent Form has been provided in an appropriate way.

(first name and family name)