Case Study Submission Form

NOTE: Exact Sciences will not claim that you endorse the Oncotype DX Breast Recurrence Score® test because you have submitted a case. Please do not provide a patient’s name, date of birth, or any information that could identify the patient. If you confirm below that you have obtained the patient’s consent to submit this case, and Exact Sciences shares the case with other professionals, it will be attributed to you and will mention your city and country of practice. If you have not obtained the patient’s consent, the case will not be attributed to you and will mention only your country to ensure that the clinical information is anonymised.

PLEASE COMPLETE THE FOLLOWING FIELDS TO SUBMIT AN INVASIVE BREAST CANCER CASE STUDY

*Required

SUBMITTED BY

PATIENT INFORMATION

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CONTINUE TO THE RELEASE FORM BELOW

TERMS OF CASE SUBMISSION

I authorise Exact Sciences Corporation and its subsidiaries (‘Exact Sciences’) to use, publish and copy the case information, including my name and location (all together, the ‘Case Submission’) for any legitimate purpose, including promotion of the Oncotype DX Breast Recurrence Score® test, without any remuneration to me. I confirm that the Case Submission is accurate information about a real case. If the ‘Patient Consent’ field above is completed with ‘yes’, I certify that I have obtained that consent after informing the patient that her/his age and pathology information may be associated with my name, city, and country, and that this information together may be used for educational and promotional purposes by Exact Sciences.

BY SIGNING AND SUBMITTING THE CASE BELOW, I AGREE TO THE ABOVE-DEFINED TERMS.

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