Pancreatic Cancer Risk Assessment

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.

Contact Information

Are you the patient? *

Have you ever been seen at Roswell Park?


Has this individual ever been seen at Roswell Park?

Would you like to join our mailing list?

Patient's Contact Information


Eligibility

Of yourthe patient's's family members that have been diagnosed, are they both/all on the same side of yourthe patient's's family? *

Are any of yourthe patient's's family members that have been diagnosed first degree relatives to each other? *

For example, a mother and a maternal grandmother that have both been diagnosed, or a father and paternal grandfather.

Do youDoes the patient have a diagnosis of Peutz-Jeghers syndrome (this is associated with mutations in the STK11 gene)? *

Have youHas the patient had genetic testing? *

Do youDoes the patient have a known genetic mutation in any of the following genes: