Medical Information Request

1 Personal Details
2 Question Details
3 Contact Details
4 Accept and Send

Personal Details

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Question Details

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Contact Details

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By clicking "accept and send," you confirm that you have read and understood the above disclaimer and that you agree to Roche’s Privacy Policy.

Please note: this form is not to be used to report adverse events or product complaints related to Roche products. To report an adverse event, please use the current procedure in force in your country. Contact details for Roche Local Safety Units.

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.

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