Thank you for ordering Caris molecular profiling via your institution’s electronic health record system (EHR). The full and complete order attestation and patient consent is listed below.
ATTESTATION & PATIENT CONSENT
This requisition constitutes an order for molecular testing from Caris MPI, Inc. (Caris). I certify (a) the services are medically necessary and will assist me in treating my patient, (b) the patient has sufficient performance status to receive additional treatment, (c) I will make available patient medical records documenting the foregoing, and (d) I supplied information to the patient regarding this testing, explained the purpose of this testing to the patient, and obtained informed consent for (i) such testing, (ii) any analysis and reports related to such testing, (iii) Caris to retain testing results, samples and related information and analysis, (iv) Caris’ use or disclosure (including to third parties) of deidentified information generated from such testing for general research and other purposes, (v) Caris’ disclosure of testing results and information to third-party payers in connection with such testing, and (vi) for Caris to contact the patient regarding the testing.