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.