One Rare Diagnosis Request Form

This form supports Sanofi's One Rare Diagnosis Program for rare disease diagnosis in Singapore. For detailed process guidance, refer to the program manual here. Please ensure all NTUH forms are downloaded and completed, here.

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Which diseases are you planning to send samples for?

Pompe

Fabry

MPS I/II

ASMD

Gaucher

Full Name (First Name, Last Name) *

Email Address *

Contact Number *

Which Health Care Professional (HCP) are you?

Physician

Nurse

Technician

Genetic Counsellor

Pharmacists

Hospital/Institute Name

If "Other" was chosen, Delivery Address (Please specify building, department, and floor) *

Delivery Remarks (Building Name, Department, Floor, Attn Name) *

No. of DBS Kits (DBS 1 kit contains 10 cards, min. 1 kit required per delivery)

- Requests received before 3:00 PM will be delivered within one (1) Business Day

- Requests received after 3:00 PM will be processed and delivered within the next Business Day

1 kit (10 cards)

2 kits (20 cards)

3 kits (30 cards)

4 kits (40 cards)

5 kits (50 cards)

I confirm I will attach the required NTUH forms when submitting samples to NTUH.

I confirm that I have read and understood the Personal Data Protection Notice, and I consent to the collection, use and disclosure of my personal data in the manner as described in the Personal Data Protection Notice

I have read the Terms and Conditions and Sanofi Privacy Policy, understand their terms, and I agree and intend to be legally bound by them. I understand that if I do not accept such Terms and Conditions and Sanofi Privacy Policy, Sanofi is unable to grant me access to the Platform and provide me with related service

I confirm that I am a licensed healthcare professional under the laws of Singapore

Error on recaptcha

One Rare Diagnosis Request Form (Singapore)