Digital E-Consent Form

This form is neither intended nor designed to record or report adverse event information.

In case of any adverse events - including any possible side effects not listed in the leaflet - or product complaints associated with the use of any Roche products, patients should talk to their HCPs and HCPs should report the details in accordance with the national requirements via the national spontaneous reporting systems to:

The National Pharmacovigilance Centre (NPC) QR Code

The National Pharmacovigilance Centre (NPC) Land Line: 19999. Fax: +966 11 205 7662 Email: npc.drug@sfda.gov.sa

Roche Products Saudi Arabia L.L.C.

Direct Tel. +966 12 211 4600

Mobile: +966 56 784 4692

Email: jeddah.drug_safety@roche.com

Roche Products Saudi Arabia L.L.C.

8042 Laysen Valley

West Umm Al Hamam dist. 2195

Riyadh - 12329

Kingdom of Saudi Arabia

www.roche.com

Saudi Arabia - Summary of Product Characteristic (SPC) QR Code

Vabysmo QR code

Country *

First Name *

Last Name *

Profession *

Specialty *

Title/Role (Optional)

SCFHS ID (Optional)

Email *

Phone *

+966

Hospital \ Clinic *

Hospital \ Clinic City *

Consent All:
I hereby, acknowledge that I have voluntarily disclosed my name, email address, phone no and other personal identifiers to Hoffmann La Roche Ltd & its affiliates
I hereby consent to Roche & its affiliates:
a) Retaining my name, email address, phone no and Personal Identifiers.
b) Contact me via Email/SMS/Digital means for the purposes of a survey and or to share information and updates (Commercial and/or educational).
c) Roche may combine Personal Data you provide with other information collected through our websites and online resources, Roche’s offline records and information provided to us by third parties. This processing activity involves the creation of a profile about you, your preferences, expertise, collaborations, and how you have interacted with us in the past in order to understand your interest, needs and preferences in our products and services so that we can best serve and communicate with you.
I acknowledge that Roche will take appropriate precautions to protect my personal information and will comply with local legislation governing data recording and usage. I confirm that I have read and understood the above provisions and conditions in their entirety.

To check Roche privacy notice click here

I Consent *

Retaining my name, email address, phone no and Personal Identifiers.

I Consent:

Contact me via Email/SMS/Digital means for the purposes of a survey and or to share information and updates (Commercial and/or educational).

Verification Channel: *
SMS:
Email:

Verification Code *

M-SA-00002028