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ROCHE RISDIPLAM COMPASSIONATE USE LABORATORY SUPPLY ORDER FORM

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Note: 3 Bags will be required to accomodate for 6 bottles for any new patient.
F. Hoffmann-La Roche Ltd ("Roche") has legal obligations to record and/or report adverse events or product complaints. Therefore, for such purposes your data will be processed in accordance with specific GVP (pharmacovigilance) or drug safety legislation, as further described in the Roche Privacy Notice for Pharmacovigilance, medical information and product complaints. Roche will keep a record of the personal data that you provide for the purpose of responding to your inquiry, to follow up on such requests, to maintain the information in the Roche global pharmacovigilance database, the Roche product complaint database and the medical information database for reference, whichever is applicable, and to comply with our legal and regulatory recording and reporting obligations. The retention time of data is in accordance with respective laws and regulations.

By including personal data of another data subject in the form, you represent the lawfulness of processing of such personal data. If you are a patient and have a medical information inquiry, you consent, by ticking the box below, to the processing of your data for the purposes mentioned above and in accordance with the Roche Privacy Notice for Pharmacovigilance, medical information and product complaints. If you do not consent to the data processing, we will not be able to reply to your message and kindly ask you to use other channels to contact us. If you are not a patient and have a medical information inquiry, ticking the box shall have no legal effect and processing of personal data will be based on Roche's legitimate interest to provide high-quality products and services and their constant improvement.

The Roche Privacy Policy provides further detailed information about your rights and how Roche processes personal data.