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.

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

To be eligible via second-degree relatives, must have three or more plus one first-degree relative -OR- a BRCA2 mutation and two or more
If 2 or more, ELIGIBLE -OR- one relative and a BRCA2 mutation in the family
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.

Genetic Mutations

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: *
Do youDoes the patient have symptoms of pancreatitis? *