Breast Cancer Risk Assessment & Prevention

Please be aware this program is usually covered by insurance, however, you may be responsible for a copay. If your insurance requires a referral, you will need to obtain one from your doctor.

To determine if this program is appropriate for you please answer a few brief questions.

Please complete the assessment below to determine if this program is appropriate for you. If you are eligible, a referral specialist will contact you within two business days to gather more detailed information.

Fields marked with an asterisk * are required.

Personal Information

About You

Are you calling for yourself, or on behalf of someone else? *

About The Patient

Have you Has the patient ever been seen at Roswell Park?

General Information

Your The Patient's Contact Information

Would you  the patient like to join our mailing list?

Your Patient's Residential Address

Your Patient's Insurance Information Optional

Your The Patient's Physician Information Optional

Risk Assessment

Family History

Are youIs the patient of Ashkenazi Jewish ancestry? *
Has a parent, sibling or child of the patient's ever been diagnosed with breast cancer? *
If yes, ELIGIBLE
Select all family members that have been diagnosed with breast cancer *
Have at least two of the patient's aunts/uncles/grandparents/first cousins ever been diagnosed with breast cancer? *
If yes, ELIGIBLE
Select all extended family members that have been diagnosed with breast cancer *
Does anyone in yourthe patient's family have a mutation in any of these genes? *
If any mutations are checked, ELIGIBLE

Prior Cancer & Treatment History

Do youDoes the patient have a history of breast cancer? *
Have youHas the patient had radiation treatment to yourthe chest for Hodgkin Lymphoma? *
If yes, ELIGIBLE

Mammography

Have youHas the patient had an abnormal mammogram? *
Have youHas the patient had a mammogram within the last year? *

General Health

Do youDoes the patient have a lump in yourhis/her breast? *
Are youIs the patient currently having regular periods? *
Do youDoes the patient have a history of LCIS or atypia on breast biopsy? * LCIS = Lobular Carcinoma In Situ, a benign (not cancer) condition
If yes, ELIGIBLE