Distributor Complaint Notification Form for Diabetes Care

Welcome to the Roche Diabetes Care Complaint Notification Portal

This form is mandatory for the real-time logging of all product complaints regarding Roche Diabetes Care products sold in distributor markets.

Please ensure you provide comprehensive details regarding the product family (BGM, IDS, or CGM) and the specific nature of the customer's issue.

If you have any questions or require assistance with this process, please reach out to your designated Roche Affiliate team immediately.

Distributor Email

Region

Please select the region from where the complaint is received

Africa

Asia Pacific

CENACA (Central Asia and Caucasian countries)

Eastern Europe

Europe

Middle East

Country

Please select the country from where the complaint is received

Reported To Distributor by

Name of the person reporting the complaint to Roche

Reporter Description

Please select the customer category for this complaint

Reporter's Email address

Email address of the person reporting the complaint to Roche

Customer Information

Please collect and add the customer information below to include: customer first name, customer last name, customer address (City, State, and Postal Code), and customer phone number.

Has the customer consented to collect their personal information and be logged in Roche CRM? (If yes, add it below. If not, do not add it below)

Customer First Name

Customer Last Name

Customer Address

Customer Address must be entered completely, including City, State, and Postal Code.

Customer Phone Number

Please enter the phone number in the correct format: (i.e. +[Country Code][Phone Number])

Date Complaint was received

Date when the problem occurred

Select the product family

BGM/IDS

CGM