Patient Registration Form for RAP Plus

Next of Kin

RAP Enrollment Form
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1. Privacy Disclosure Statement

Roche (Philippines) Inc. (Roche), obtains, uses and discloses personal information as set out below as part of Roche’s patient support programs which aims to provide patients duly prescribed with Roche products better information about their disease or better access to its medicines.

Our Policy

Personal information is processed in accordance with the following:

a. Republic Act No. 10173 or the “Data Privacy Act of 2012”

This act explains:
  • Your rights as a data subject;
  • Roche’s duties as personal information processor/ controller; and
  • How you may access your personal information held by Roche, seek correction of that information, and make a complaint about a breach of this law

b. Roche Code of Conduct (Section on Data Privacy):

We process personal data with due care.

Roche operates around the globe, using various electronic systems to process, exchange and share information between units within the Roche Group and with the third parties. Increasing cooperation in the fields entails the exchange of personal data. This trend is reinforced by the increasing use of modern telecommunications and electronic collaboration tools and platforms.

Roche is committed to respecting data privacy and has developed principles that must be consistently applied when processing personal data within the Roche Group and by its business partner.

Being active in clinical and genetic research, Roche must ensure that identifiable health information is carefully processed. Roche takes due care to prevent any misuse of or unauthorized access to such identifiable health information within its control. All processing of personal data (e.g. data of employees, business partners, customers and suppliers) must be on the compliance with applicable data privacy laws and Roche principles.

Collection of Information

We collect personal information from you as the patient named in this portal. Personal Information:

  • is required to assess your eligibility to participate in the Roche Program
  • is required to monitor your compliance to the Roche treatment by your physician
  • is required by the Roche Local Safety Unit for pharmacovigilance purposes

In addition to the purposes as stated above, we may use your personal information for research purposes such as:

  • Establishing patient’s duration of therapy
  • Effectiveness of Patient Programs to monitor your compliance to the Roche treatment prescribed by your physician including but not limited to treatment initiation

Disclosure of Information

We may disclose your personal information to third-party service providers who will be tasked with the administration of the Roche Program.

2. Personal Information Required

Please ensure to complete all applicable sections in the Roche Program Enrollment Form/ such as:

  • Full name
  • Telephone/ Mobile number
  • Full name of alternate contact and their telephone/ Mobile number
  • Treatment Protocol and Dose
  • Planned Treatment Duration

If this information is not provided, we may not be able to process your enrolment.

Legal Statement

No warranty and no liability

While Roche is making great efforts to include accurate and up-to-date information, we make no representations or warranties, express or implied, as to the accuracy or completeness of the information provided on this Website and disclaim any liability for the use of this site or any site linked to it. Roche may change this site at any time without notice but does not assume any responsibility to update it. All users agree that all access and use of this Website and on any Website linked to from this site and the content thereof is at their own risk. Neither Roche nor any other party involved in creating, producing or delivering this Website or on any Website linked to from this site shall be liable in any manner whatsoever for any direct, incidental, consequential, indirect or punitive damages arising out of your access, use or inability to use this Website or any Website linked to from this site, or any errors or omissions in the content thereof.

No offer and no solicitation

The information provided on this Website does not constitute an offer of or solicitation for the purchase or disposal of, trading or any transaction in any Roche securities. Investors must not rely on this information for investment decisions.

Forward-looking information

This page may contain forward-looking information. Such information is subject to a variety of significant uncertainties, including scientific, business, economic and financial factors, and therefore actual results may differ significantly from those presented.


Links to third party pages are provided for convenience only. We do not express any opinion on the content of any third party pages and expressly disclaim any liability for all third party information and the use of it.


All mentioned trademarks are owned by or licensed to a Member of the Roche Group.


The Website of Roche and the information contained and referenced therein are for informational purposes only. Any reproduction, retransmission or other use is strictly prohibited. Request for permission to reproduce any information contained on this Website should be addressed to the Roche Webmaster.

How to Contact Roche

For questions or if you wish Roche to amend or delete your profile, please contact us in writing (by post), as follows:

img Roche (Philippines) Inc.
Unit 801, 8/F, The Finance Centre
26th Street corner 9th Avenue
Bonifacio Global City, Taguig, 1634
Phone: (+632) 7718-7777

Unless explicitly stated otherwise, this Privacy Statement applies to Roche (Philippines) Inc. websites.

Select file
Select file
Select file

Please ensure that forms are completely filled out and signed prior to submission.

System will allow only following file types: gif, jpeg, img, png, jpg, ppt, pptx, doc, docx, xls, xlsx, xml, txt, rtf, pdf.