Online Pump Sales Order

Accu-Chek Solo Micropump System - Resupply Sales Order

Healthcare Team details

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

* Mandatory fields

Healthcare Team details

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

* Mandatory fields

Purchase Type *

Prescribing Clinician Full name *

Diabetes Educator/Healthcare Professional Pump Trainer Full Name *

Hospital/Clinic Name *

Email address *

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

Phone number *

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.

Delivery Address for Pump Order *

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.

Roche Territory Manager 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 (if required for your patient's Health Fund):

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 Roche Diabetes Care Australia.

Leave this field blank

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Accu-Chek Solo Micropump System - Resupply Sales Order