Medical Information Request

Please note: Any personal data you may provide in relation with this enquiry will be retained in a secure database and may be transferred to a server based on the United States. It will only be used for the purposes of answering this inquiry and/or reporting purposes as required by law or regulatory authority. If you would prefer that Roche does not store your personal data, please let us know.

1 Personal Details
2 Question Details
3 Contact Details
4 Submit Request

Personal Details

Required field.

Required field.

Required field.

Required field.

Required field.

Question Details

Required field.

Contact Details

Required field.

Required field.

Required field.

Required field.

Required field.

Required field.

Take your Next Action

Roche will keep a record of the personal data that you provide for the minimum period necessary for the purpose of responding to your inquiry, to follow up on such requests and maintain the information in a Medical Information database for reference.

 

By ticking the box below you consent to processing of your data (where consent is the legal basis for processing of your data) for the purposes mentioned above and in accordance with Roche Privacy Policy - which provides you with detailed information about your rights and how Roche processes personal data.

 

You are also aware that in case Roche F. Hoffmann La-Roche Ltd has legal obligation to report an adverse event, your data will be processed in accordance with specific GVP (pharmacovigilance) legislation, as described in the Privacy Notice for Pharmacovigilance.

Your data will not be used for any other purpose.

 

Please note: this form is not to be used to report side effects related to Roche products. To report a side effect, please contact your local Roche safety unit. For country-specific contact details visit www.roche.com/products/local_safety_reporting

 

Required field.

Required field.