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    Medical Sample Request Form

    Please use this form to request free medical samples from Roche Saudi Arabia. Ensure all required fields are completed accurately. The form allows you to select the product, dosage form, and quantity (up to a maximum of 2). Kindly provide your full address for delivery and consent to the processing of your data for this request and future reconciliations. An optional checkbox is available for opting into future communications from Roche

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      I Consen Roche will keep and process his data regarding this request and for future reconciliation
     
     
      I Consent to email and/or telephone communication for commercial/promotional/medical purposes If you give us your consent, we will use your communication details to send you Roche promotional material and other science news that may interest you, get your feedback, send you medical education, Roche product and services, Roche sponsored programs, events, and initiatives. You have the right to withdraw your consent at any time and be removed from the relevant Newsletter and written message services. I hereby, acknowledge that I have voluntarily disclosed my personal data such as, but not limited to my name, email address, contact number to Roche Products Saudi Arabia and its affiliates. I hereby consent to Roche and its affiliates Using my personal data to contact me via, including but not limited to SMS, email, and letters and alike for the purposes of a survey and to share information and pertinent updates Retaining my personal data I give my consent to the financial support/transfers of value that will be provided by Roche to me and disclosure of such financial support to SFDA in accordance with the guide. The personal data owner has filled and agree the consent form himself/herself
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    • 23.05.2024
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