Healthcare Team details
Please review the terms and conditions of Accu-Chek Solo Micropump System - Resupply with your customer before proceeding.
* Mandatory fields
Please enter the number in the correct format. For example: +61878564567
Please use the fields below to provide full address details for where the insulin pump kit should be delivered. Note: If the delivery address provided is not the address of the clinic/hospital, you are confirming that adequate support is in place for the person with diabetes to be comfortable in the use of the insulin pump.
To allow for pump order processing and delivery, pump initiation date must be minimum 2 weeks from today’s date.
Please attach Hospital Purchase Order.
Please attach Specialist letter of clinical need:
Please attach Health Fund Funding Application Form (if required for your patient's Health Fund):
Roche Diabetes Care Australia (RDCA) respects your privacy. We collect your personal information for the purpose of your interaction with us and for research and marketing. We do not sell your personal information to third parties.
The controller is Roche Diagnostics International AG, Basel Branch Diabetes Care - 4052 Basel, Switzerland, acting as the parent company of affiliates engaged in the diabetes care business unit. In the event that your personal data is covered by the EU General Data Protection Regulation (“EU”) 2016/679 (“GDPR”), the EU representative is Roche Privacy GmbH, Emil-Barell-Str. 1, D-79639 Grenzach-Wyhlen. The local affiliate in your country of residency may be considered a controller to the extent it participates in the activities described below (more information about Roche’s affiliate in your country of residency is available on www.accu-chek.com.au). We will send you marketing emails provided that you agree to this operation, and will retain the data as long as we maintain interactions with you and not more than three years after the last contact. By moving forward, you explicitly agree to the processing of data revealing your health for the purpose of automatically tailoring and sending emails.
We may share your data with Roche’s affiliates and with service providers to the extent necessary for this purpose, which may imply a transfer in a geographic region that imposes different privacy obligations than your country of origin. In this case, our internal data transfer agreement warrants that the appropriate measures are in place within the Roche group, and we similarly implement appropriate contractual safeguards with service providers. To exercise your rights (of access, rectification, restriction, objection, erasure, or portability), please contact us at [email protected]. You are also entitled to lodge a complaint with the authority of your country of residency.