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      First Name*

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      Consent to be contacted by Roche Local Safety Unit

      Disclaimer:
      You are aware that Roche (Philippines) Inc. has a legal obligation to collect and report potential adverse events brought to its attention to Health Authorities. In such cases, your data will be processed with the greatest care and diligence in accordance with specific GVP (pharmacovigilance) legislation, as described in the Roche Privacy Policy related to pharmacovigilance. Your data will not be used for any other purpose. Privacy Policy

        First Name*

        Last Name*

        Email*

        Phone

        Your Message*

        Patient identifiers

        Disclaimer:
        You are aware that Roche (Philippines) Inc. has a legal obligation to collect and report potential adverse events brought to its attention to Health Authorities. In such cases, your data will be processed with the greatest care and diligence in accordance with specific GVP (pharmacovigilance) legislation, as described in the Roche Privacy Policy related to pharmacovigilance. Your data will not be used for any other purpose. Privacy Policy