Order Form - Second Opinion Service

Order Form - Second Opinion Service

This service is available for a one-time fee of $1,495.
This form collects the information required to prepare an independent second medical opinion by a licensed consulting oncologist.

Important Information About Eligibility for the Second Opinion Service
Please read the following information carefully before ordering this service. This medical second opinion is not suitable for all patients, and we can only provide it if all eligibility criteria listed below are met.

1. Type of cancer diagnosis
This service is available only for patients diagnosed with a solid tumor.
Solid tumors are cancers that form a mass in an organ or tissue (for example: breast, lung, colorectal, prostate, ovarian, melanoma, sarcoma, etc.).

This service is not available for patients with:
- Leukemia
- Lymphoma
- Multiple myeloma
- Other hematologic (blood-based) malignancies
If you are unsure whether your cancer is considered a solid tumor, please consult your treating physician or contact us at support@genomate.health before ordering this service.

2. Required molecular testing (Next-Generation Sequencing, NGS)
To provide a clinically meaningful second opinion, you must have already completed comprehensive molecular testing using next-generation sequencing (NGS) of your tumor.

This service requires an NGS test that analyzes at least 50 cancer-related genes.

Examples of commonly used NGS test providers and platforms that often meet this requirement include (this list is not exhaustive):
- Foundation Medicine (e.g. FoundationOne® CDx, FoundationOne® Liquid CDx)
- Caris Life Sciences
- Tempus
- Guardant Health (comprehensive panels)
- Illumina-based or other large-panel NGS tests performed by CLIA-certified laboratories
If you are unsure, please review your molecular pathology report, consult your treating physician, or contact us at support@genomate.health before ordering this service.

3. Location restrictions
Due to medical licensing regulations, this second opinion service is offered only in specific U.S. states.
- Currently, the service is available exclusively to patients located in Texas, Georgia, and Missouri.
- You must be physically located in Texas, Georgia, or Missouri at the time of the consultation.
If you reside in or are located outside of Texas, Georgia, or Missouri, we are currently unable to provide this service, even if all other criteria are met.

Patient Data
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
MaleFemale
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Street Address*
City*
State*
At this time, the Second Opinion Service is available only in the listed states.
Zip Code*
Please make sure to fill this field accurately, as you will need this data to download your report.
NoYes, please invite the support person identified below to attend the consultation and receive the results. By selecting this option, I authorize Genomate Health Inc. and the consulting healthcare professional to share information related to this second opinion service, including medical information and the consultation report, with this individual. I understand that this authorization may be revoked at any time by notifying Genomate Health Inc., to the extent that said information has not already been shared.
- Support Person Details
- Support Person
  
  First NameLast Name
- Support Person Email
  example@example.com
- Support Person Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Medical Details
- For the Second Opinion Consultation, please upload the relevant medical documents so the following information can be confirmed:
  - Tumor type
    e.g., pathology report
  - Molecular profile or genetic test results
    e.g., NGS reports (such as FoundationOne, Caris, Tempus, etc.), IHC results, FISH results
  - Treatment history
    e.g., surgeries, medications, chemotherapy, radiation, or other treatments
  - Most recent imaging results
    e.g., CT or MRI report/description — please do not upload the image files
  Supported file formats: PDF, DOC, DOCX, JPG, JPEG, PNG
- Medical Reports*
  
  Please upload only relevant medical documents. The accuracy, completeness, and timeliness of the information you provide directly affect the second opinion. Incomplete or inaccurate information may impact the conclusions of the report. The information and documents you upload will be handled securely and used solely for the purpose of preparing your second opinion, in accordance with applicable laws.
  Cancelof
- Please list any specific questions you would like the Consulting Oncologist to address.

Telehealth Informed Consent
I understand that this second opinion consultation will be provided using telehealth technologies, which may include video conferencing, audio communication, secure electronic messaging, and electronic document review and signing. 

I understand that Genomate Health Inc. provides administrative and technical support for this service and does not provide medical care, and that all medical services, opinions, and clinical decisions are provided solely by an independent licensed consulting healthcare professional.

I confirm that I will be physically located in a U.S. state where this service is offered at the time of the consultation, as required by applicable medical licensing and telehealth laws, and I understand that the consultation cannot proceed if this requirement is not met.

I understand that telehealth involves the electronic transmission of medical information and that there are potential risks, including technical failures, interruptions, or unauthorized access despite having reasonable security measures in place.

I understand that telehealth services may not be equivalent to an in-person medical evaluation and that no physical examination will be performed. I understand that the consulting healthcare professional may determine that telehealth is not appropriate in all circumstances and may recommend follow-up with my treating physician or in-person care. 

I understand that the consultation may, but will not necessarily, be audio and/or video recorded for documentation and quality purposes, and by signing this form I consent to such recording if it occurs.

I understand that this service is not intended for medical emergencies or urgent care situations, and that in the event of an emergency I should seek immediate medical attention from my treating physician or local emergency services. 

I understand that I may withdraw my consent to receive healthcare services via telehealth at any time by notifying Genomate Health Inc. or the consulting healthcare professional.
Second Opinion Service Consent & Limitations
I understand that this service provides an independent second medical opinion based on the medical information and documents that I submit. I understand that a second opinion is advisory in nature and does not replace, supersede, or substitute the care, diagnosis, or treatment provided by my treating physician or healthcare team.

I understand that this service establishes a limited consulting physician–patient relationship solely for the purpose of providing this second opinion and any associated consultation, and does not include ongoing care, treatment, or follow-up, unless otherwise expressly agreed in writing.

I understand that treatment options, drugs, or therapeutic strategies discussed as part of this second opinion are provided for informational purposes only and do not constitute a prescription or directive for treatment. I understand that this service does not guarantee any specific outcome, including treatment response, disease progression, survival, or the absence of adverse events, and that all treatment decisions remain the responsibility of my treating healthcare team.

I understand that, in forming this second medical opinion, the consulting healthcare professional may use clinical decision support tools, including Genomate®, a clinical decision support software for precision oncology as described in Section 520(o) of the Federal Food, Drug, and Cosmetic Act (FDCA). I understand that such tools are intended to support, but not replace, the healthcare professional’s independent clinical judgment, and that any opinions, interpretations, or recommendations provided as part of this service are solely those of the consulting healthcare professional, based on their professional assessment and my individual clinical circumstances.

I understand that this second opinion is based solely on the review of medical records and information provided and does not include a physical examination or in-person evaluation. As a result, the consulting healthcare professional may not have access to information that would otherwise be obtained through an in-person assessment, which may affect the completeness or accuracy of the opinion provided. I understand and accept these limitations and the associated risks inherent in a record-based, remote second opinion.

I understand that the consulting healthcare professional provides this opinion within the scope of their medical licensure applicable to my location.
HIPAA Authorization & Privacy Acknowledgment
I authorize Genomate Health Inc. and the consulting healthcare professional to collect, use, and disclose my personal information and protected health information for the purpose of providing this second opinion service. This may include, but is not limited to, information relating to my medical history, prior diagnoses, pathology reports, molecular and genetic profiling results (including NGS and other biomarker testing), imaging reports, treatment history, medications, laboratory results, and any consultation reports or communications generated as part of this service. This authorization includes the collection, use, and disclosure of genetic information, including molecular and genomic test results, for the purpose of providing this second opinion service, in accordance with applicable law.

I understand that my health information may be shared with the consulting healthcare professional, my treating healthcare providers, and any support person I have authorized, as well as with administrative or technical service providers involved in delivering this service, as necessary and in accordance with the Privacy Notice.

I acknowledge that I have read and understand the Privacy Notice (www.genomate.health/legal/second-opinion-service-privacy-notice) and the Terms and Conditions (https://www.genomate.health/legal/second-opinion-service-terms-conditions), and how my personal and health information will be processed in accordance with applicable laws. I understand that I may revoke this authorization at any time by contacting Genomate Health Inc. at privacy@genomate.health, except to the extent that action has already been taken in reliance on it. Unless revoked earlier, this authorization will remain in effect until completion of the second opinion service.

I understand that this authorization is required to provide the second opinion service, and that the service cannot be delivered without it.

If I am submitting information on behalf of another individual, I confirm that I am legally authorized to do so.
Patient Signature*

Clear
By signing above, I confirm that all information I have provided is accurate and complete to the best of my knowledge, that I am either the patient or a legally authorized representative of the patient, and that I knowingly and voluntarily consent to the second opinion consultation and related services as described above and in the applicable Terms and Privacy Notice.

Second Opinion Consultation Appointment*
By clicking the checkbox, you understand that this is a paid medical second opinion service, that payment is required before the Service begins, and that fees are non-refundable once the Service has been initiated or delivered, as described in the Terms and Conditions.

Consultation Fee*

Second Opinion Service

$1,495

Product Name

$ Free Quantity

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
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Order Form - Second Opinion Service

Patient Data

Support Person Details

Medical Details