Patient Form

Do you want to find an appropriate treatment to your medical condition? Do you need an personalized assistance during your treatment ?  

You are at the right place ! Gene Story will help you in every step.

Please complete this form and then you will get access to you personal protected account.


Personal Information


First Name (required)

Last Name (required)

Date of birth (required)



Gender (required)
ManWoman

Contact Informations

Address (required)

Email (required)

Telephone (required)

Emergency contact


Contact Name


Contact Phone number

Alcohol and tobacco


How many beers do you consume per week ?


How many glasses of wines do you consume per week ?


Do you smoke ?

If yes, precise:

Health status


Do you have allergies or food intolerances or drugs ? (required)

If yes, precise:


Are you under medical treatment ? (required)

If yes, precise:


Do you have a medical condition ? (required)


Could you precise which type of condition do you have ? (required)

If other, precise:


How long have you been with this condition ? (required)


Are you followed by a family doctor ? (required)


Are you ready to participate to a clinical trial ? (required)

Other informations


Gene Story's long term goal is to collect patient's biological samples in order to match individuals to clinical trials according to their genetic profile in the future. Are you willing to give a sample of saliva ?


How did you hear about us ?

If other, precise:


What is the best moment to contact you ?


Would you like to subscribe to our newsletter to find ongoing studies and stay up to date with latest news ?(required)
YesNo

Terms & Conditions

Gene Story is a for-profit organization dedicated to finding the best treatments and therapies for patients by matching them with specific clinical trials.

We ask for your permission to be able to communicate with you when certain research projects for which you could be a participant become available.

You have the choice of participating or not participating in the research projects that will be suggested to you. Your decision will not affect your eligibility for future clinical studies.

You have the power to revoke your authorization to contact you for research projects at any time on simple verbal notice without having to justify the reasons of your decision.

I agree that my contact details entered above will be used by the Gene Story team to contact me in order to propose research projects for which I may be eligible.

I authorize Gene Story to forward my information to researchers to whom I would be eligible in a confidential and ethical manner.

I understand that the data collected may be stored in a database for future studies and each participant will be assigned an identification code that guarantees his / her anonymity and confidentiality.

I agree to participate with Gene Story to find a personalized treatmentI accept the terms and conditions