Pancreatic 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 Cancer Institute?


Has this individual ever been seen at Roswell Park Cancer Institute?

Would you like to join our mailing list?

Patient's Contact Information
Eligibility

Do youDoes the patient have two or more first degree relatives (mother, father, sister, brother, child) who were diagnosed with Pancreatic cancer?

Do youDoes the patient have three or more blood relatives, with at least one first degree relative (mother, father, sister, brother, child), who were diagnosed with Pancreatic cancer?

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 genetic mutation in any of the following genes; P16, PALB2, Lynch Syndrome?

Please specify which gene(s)

Do youDoes the patient have at least one first degree relative diagnosed with Pancreatic cancer?

Do youDoes the patient have a genetic mutation for BRCA2?

Do youDoes the patient have at least one first degree relative or two family members diagnosed with Pancreatic cancer?