Application Form for the Familial Pancreatic Cancer Genetic Study

If you would like to be contacted to learn more about our study, please complete the following information and
submit the form below:
Or Call: Kate Sargent at (313) 578-4240
Or toll-free at 800-KARMANOS (1-800-527-6266) and ask for extension 4240

PLEASE READ BEFORE COMPLETING APPLICATION:

Participants will not receive "gene test results" from this study. Since one of the goals of this study is to understand
the role of genes in familial pancreatic cancer, the meaning of an individual result may not be understood for some time until
accrual and analysis of the data are complete.

All personal information received will be kept confidential as required by law.

Name and at least one of: address, phone, or email are required.

Title:
Name*:  
Address:
City: State:
Country: Zip:
Daytime Phone:
Email:  
Have YOU ever been diagnosed with pancreatic cancer?
How many of you relatives were diagnosed with pancreatic cancer?
Please check all the relatives who were diagnosed with pancreatic cancer:
       
       
       
       
       
       
       
       Other:
Please type in any comments or questions here.
Thank you for telling us about your family. You will hearing from us soon.