Consent Submission

Online Consent Form

Dear Healthcare Professional,

Roche Singapore ("Roche") Pte Ltd is committed to deliver innovative pharmaceutical products and related services to healthcare professionals and to the community.

In order to provide with the services outlined in our Privacy Policy, e.g. to respond to your requests or inquiries, to complete a transaction or to personalize your experience, we would like to collect some of your personal information including but not limited to name, address, e-mail address, and telephone number ("Your Data").

We would therefore be grateful if you would please complete your details and confirm your agreement to your data being managed in accordance with our Privacy Policy and applicable law of Singapore and for the purposes specified above.

* Required fields

Personal Information

Title * Please Select

First Name *

Last Name *

Profession * Please Select

Specialty * Please Select

Contact Information

Organisation Name *

Street Address *

City *

Post Code *

Country *

Email *

Mobile number

Office Number

I have read, understand and agree that personal information will be collected, stored and used in accordance with Roche Singapore Pte Ltd Privacy Policy for the below purposes.

I consent to receive communications from Roche Singapore Pte Ltd and its affiliates regarding (1) Roche's products and services; (2) Roche sponsored programs, events and initiatives; (3) customer feedback; and (4) medical and educational information.

Permission can be updated under your channel preference.