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Reimbursement Support Program

Doctor Consent Form

Have your prescribing doctor complete the ‘Doctor Consent Form’ and E-Mail the completed consent form to AbbottDiabetesCareSA@supportwindow.co.za

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Reimbursement Support Program

Motivation Form

This form was developed to guide the HCP in the completion of the relevant health information and possible motivation which is based solely on the HCP’s scientific evaluation and knowledge of the situation. 

Have your clinical advisor complete the ‘Motivation Form’ and E-Mail the completed form to AbbottDiabetesCareSA@supportwindow.co.za

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Reimbursement Support Program

Patient Consent Form

Download the Patient Consent form and E-Mail the completed form to AbbottDiabetesCareSA@supportwindow.co.za

Download Patient Consent Form

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The CDE Pharmacy (Pty) Ltd
T/A The Centre Pharmacy

Pharmacy Nr: Y03847
81 Central Street, Houghton Estate
P.O.Box 2900, Saxonwold, 2132, South Africa
Tel: +27117126000
Fax: +27117286661

Responsible Pharmacist: Imraan Ahmed Bismilla
(P00935)

Consent

I consent to the transfer of my personal information to Medtronic Diabetes. I understand that Medtronic shall only process my personal information as is necessary for the purposes of this transaction. 

I understand that, subject to applicable laws, and upon my request, I may (i) have access to this personal information stored and used by Medtronic, (ii) ask for the correction of any incorrectly stated information, and (iii) revoke the consents given in this form at any time by providing written notice to Medtronic at zadiabetes@medtronic.com.  Please note that Medtronic may need to request proof of identity in order to process your request. I understand that I have the right to lodge a complaint with the Regulator at inforeg@justice.gov.za.

I consent to Medtronic contacting me through telephone calls, SMS’s, and emails for the purpose of on-going patient care. For purposes of ongoing patient care, Medtronic will create a Medtronic Diabetes Profile which records the device allocated to the patient, the device serial number for purposes of the warranty and any product observations which might have been logged to that medical device (required by regulatory).  This enables the patient to contact a 24-Hour Product support line for support on that specific medical device. 

I further consent to Medtronic contacting me through SMS’s and emails for the purpose of informing me of any Medtronic products.  This will include Medtronic training material regarding the medical device, support emails on product discontinuation and upgrade availabilities on the patient’s specific medical device when nearing the warranty expiry and consumable updates/changes. 

Should I provide such consent, I will be able to withdraw such consent at any time by sending a written request that communications cease to the following e-mail address: zadiabetes@medtronic.com I hereby affirm that I am over the age of majority and have the full contractual capacity to provide consent and am under no duress or undue influence at the time of my signing of this form. I have read the consent form, prior to its execution; I fully understand the contents thereof.