Online Pump Sales Order

Accu-Chek Solo Micropump System - Continuing Pump Sales Order

Healthcare Team details

Please review the terms and conditions of Accu-Chek Solo Micropump System - Continuing with your customer before proceeding.

* Mandatory fields

Purchase Type *

Prescribing Clinician Full name *

DE/HCP pump trainer Full name *

Email address *

Phone number *

Please enter the number in the correct format. For example: +61878564567

Hospital/Clinic name *

Delivery Address *

Suburb *

State *

Postcode *

Pump Initiation Date *

Day

Month

Year

To allow for pump order processing and delivery, pump initiation date must be minimum 2 weeks from today’s date.

TM name

Purchase Order number

Please attach Hospital Purchase Order.

Files must be less than 5 MB.
Allowed file types: jpg jpeg pdf.

Hospital Purchase order

Please attach Specialist letter of clinical need:

Files must be less than 5 MB.
Allowed file types: jpg jpeg pdf.

Specialist letter of Clinical need *

Please attach Health Fund Funding Application Form:

Files must be less than 5 MB.
Allowed file types: jpg jpeg pdf.

Health Fund Funding Application Form *

If you have not attached the hospital Purchase order, please organize for hospital Purchase order to be sent to australia.insulinpumps@roche.com. Your order will not be processed until the Hospital Purchase order is received by RDCA.

Leave this field blank

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Accu-Chek Solo Micropump System - Continuing Pump Sales Order