Start Your Case Review | Cancer Clarity MD

1. Patient Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

Country of Residence *

Are you the patient, or submitting on behalf of a patient? *

Patient Family Member Caregiver

2. Medical Information

Primary Diagnosis or Condition *

Cancer (Solid Tumor) Blood Disorder (Leukemia, Lymphoma, Myeloma) Other Hematologic Condition (Benign)

Year of Diagnosis

Current Treatment Status *

Specific Questions for the Specialist

Please describe your main concerns or specific questions about your diagnosis or treatment options.

3. Medical Records Upload

What to upload

Pathology / biopsy reports

Imaging reports (CT, MRI, PET)

Genomic / NGS testing results

Recent laboratory results

Oncologist / clinic notes

Treatment history summary

Don't have everything yet? You can submit now and provide additional records after - our team will follow up.

Click to upload or drag and drop

PDF, DOCX, JPG - up to 50MB total

4. Consultation Package

Written Second Opinion

Fee discussed upon inquiry

Structured written opinion from a board-certified specialist delivered within 48 to 72 hours of record receipt.

Written Opinion + Video Consultation Recommended

Fee discussed upon inquiry

Includes the full written report plus a direct video consultation with the reviewing physician to discuss findings and answer your questions.

Patient Consent & Acknowledgment

By submitting this form, I confirm and agree to the following:

Independent Advisory Only. I understand that Cancer Clarity MD provides an independent specialist opinion and does not establish a treating physician-patient relationship. The advisory report does not replace the clinical judgment of my treating oncologist.
Accuracy of Submitted Records. I confirm that the medical records I am submitting are authentic and complete to the best of my knowledge. I accept responsibility for any material inaccuracies in the documents I provide.
Voluntary Engagement. My engagement with Cancer Clarity MD is entirely voluntary. I am free to disregard, share, or act upon the advisory report at my own discretion, in consultation with my treating medical team.
Privacy and Data Use. I consent to Cancer Clarity MD receiving, storing, and using my medical records solely for the purpose of the requested independent review, handled in accordance with HIPAA.
No Emergency Services. I understand that Cancer Clarity MD is not an emergency service and is not appropriate for urgent or life-threatening situations.
Fee and Refund Policy. Fees are non-refundable once the specialist review has commenced.
Medical Disclaimer. I have read and understood the Cancer Clarity MD Medical Disclaimer and agree to the terms stated therein.

I confirm that the information provided is accurate and that I understand this consultation is an independent second opinion service and not a substitute for direct medical care. I agree to the Terms of Service, Privacy Policy, and the Patient Consent terms above.

Your information is transmitted securely and protected in accordance with HIPAA and applicable healthcare privacy standards.

Download Medical Disclaimer (PDF) · Download Patient Consent Form (PDF)