Request Your Tumor Blueprint
If you have questions about the type of tumor specimen that is needed for this profiling, please email email@example.com.
Please discuss profiling with your physician prior to submitting your forms as his or her authorization is required.
Patient Background Form (Submit Electronically)
This form provides contact information for you and your doctor, as well as some background about your cancer and treatment you have received. We will use this information, together with data from your molecular profile, to generate our tumor profiling report. Please fully complete the form and submit your information to Clearity using our secure online system. Please consult your doctor’s office if you have questions about the details of your medical history.
Clearity Consent and Authorization Forms (Download Forms)
1. Tumor Molecular Profiling Assistance Consent Form: gives Clearity permission to have your tissue samples tested and to have your results and clinical information incorporated into the Clearity Foundation Database. Your information will remain confidential.
2. Clinical and Molecular Profiling Data Consent Form: gives Clearity permission to use your clinical history and test results to generate the Clearity Tumor Molecular Profiling Report and/or add them to the Clearity Foundation database to facilitate discussions with Clearity staff. Your information will remain confidential.
3. Repository Consent Form (Optional): gives Clearity permission to have your tumor molecular profiling data and associated clinical information incorporated into the Repository and used for research purposes. This information will be de-identified so that none of your personal information will be stored in the repository.
4. Clearity Authorization for Release Form: allows Clearity to request and obtain your tumor sample and medical records.
5. Foundation Medicine Authorization for Release Form: This form is necessary to obtain genomic tests for your tumor. Note: international patients should contact us for more information.
If insured, email a front and back copy of your insurance card(s) to firstname.lastname@example.org.
Financial Assistance Form (Submit Electronically)
While Clearity provides patient support services for free, the cost of the molecular testing will vary depending on your insurance. If you require financial assistance, please do not hesitate to fill out this form.
Please send us copies of the following:
1. Most recent pathology report (corresponding to the sample you would like us to profile)
2. Pathology and operative report(s) from original diagnosis as well as staging surgery
3. Oncology flowsheets (records indicating drug(s), doses, and dates given) OR pharmacy records for the chemotherapy regimen received prior to collection date of sample to be profiled AND subsequent treatments, if any
4. Summary of chemotherapy treatments with dates since diagnosis (e.g., from recent oncology office visit/progress note)
5. CA-125 data summary from at least the past year (from diagnosis, if possible)
6. CT/PETCT/MRI reports from each recurrence and from the past year
7. Recent oncology office visit/progress note
8. BRCA test result report, if applicable
Please submit the completed forms and requested records to Clearity via email (email@example.com) or fax (858-657-0265). Submission of all requested documents will help Clearity ensure you receive your testing results in a timely manner.