Join Coloplast^® Care – fill in your information below

Coloplast welcomes you to join Coloplast Care. Simply fill out the form below to sign up and start your Coloplast Care program with tailor-made support and advice. You will receive your first email today.

1. Your information
2. Your ostomy
3. Your life

Why we need your personal information

Every person with an ostomy is unique; the more you tell us about yourself and your situation, the better we can help you. With every detail you provide, the advice you receive will become more relevant.

More info = more support

Your phone number enables us to give you personal advice over the phone – and by giving your address, you can get free samples and accessories.

Title

First name*

Last name*

Date of birth*

Gender *

Address *

City *

State *

Postal code *

Home Phone*

Mobile Phone*

Email address*

Confirm email address*

Do you know your surgery date?*

Please check the box to ackknowledge that you have read and understood the privacy statement*

I have read and understood the privacy statement

Privacy statement
Coloplast respects the privacy of your personal information and will protect the confidentiality of the information contained on this form. The only time the information may be used or shared is if it is (1) required by law; or (2) to provide you with information about Coloplast products, services and wellness education. You may be contacted by Coloplast, its agents, affiliates, contractors, or supply or service providers by telephone, email, US Mail, or other means of communication only for the purpose stated above. If you choose not to receive communication from Coloplast, please contact us at 1-888-726-7872 or email samples@coloplast.com to request that communication be discontinued.

Join Coloplast® Care – fill in your information below

Why we need your personal information

More info = more support

Join Coloplast^® Care – fill in your information below