Patient Informed Consent Form


I, undersigned:

(first name and family name of the patient) 

Barcode of the collection kit: *

(The barcode contains up to 10 characters that includes both numbers and letters)

1. *

I authorize the processing of my Samples and personal data (identified in Section 4 of the document) by OncoDNA, without the supervision of a health professional and as defined by the applicable law.

2. *

I authorize my medical doctor to send my Samples to OncoDNA so that the selected Test is carried out.

3. *

When the Test Report has identified a treatment that is still under development, I authorize OncoDNA to contact my medical doctor to put him/her in contact with pharmaceutical companies and/or centers that carry out clinical trials to assess the relevance of my participation in these trials.

4. *

In order to continue to improve the quality and accuracy of the Tests and Reports for future patients, I authorize my medical doctor to provide to OncoDNA with his/her therapeutic decision and post-treatment clinical data once the test is completed.

5. *

In order to provide increasingly accurate and personalized services and Reports, I authorize OncoDNA to integrate, in an anonymous way, my Analysis Results and post treatment clinical data into its database. In this respect, please note that this database has already been enriched with data from previous patients who have consented to its integration and reuse to improve the Tests and Reports for the future patients.

6. *

In order to continue to improve the quality and accuracy of the Tests and Reports for future patients, I authorize OncoDNA and/or its partners to use my pseudonymized Residual Samples for scientific purposes and/or to participate to clinical trials.

7. *

In order to allow the approval of the OncoDNA’s Tests and services according to the regulatory and/or normative requirements of third countries, I authorize OncoDNA to use my pseudonymized Residual Samples for validation purposes specific to the territory concerned.

Witness (first name and family name):

(A witness is required solely if the patient or his/her legal representative is physically or legally incapable of giving consent)

I confirm that I have no connection to OncoDNA and that the information contained in this ICF has been provided to the subject appropriately.