If one or more people in your family have been diagnosed with pancreas cancer, please fill in the data below. We will then send you a questionnaire so that you can register your family with the NFPTR. We appreciate your helping us learn about pancreas cancer occurring in families.

Fields marked with * are required

Name*

Email*

Phone Number

Address*

City*

State/Province*

Zip Code*

Country

Number of family members with pancreatic cancer (including yourself, if applicable)

Relationship of afflicted individual(s) to you

Paper, please?

Any Additional Comments (optional)