me+ Program Form: Enroll Your Patient - Ostomy Care

Patient Information

First Name

Last Name

Email Address

Phone Number

Telephone Type

Patient Retailer

Country*

Surgery Type

Surgery Date

HCP Information

Your First Name

Your Last Name

Your Email Address

Your Phone Number

Facility Name

Facility ZipCode

Patient Consent Acknowledgement

By completing this form on behalf of you and your patient, you acknowledge the following:

Your and your patient’s privacy is important to us. Convatec will not share your patient’s or your personally identifiable information with an unrelated party without your and your patient’s permission. Please read our privacy policy where you can find detailed information on how we protect and use customer information; we can also provide you and you patient with a copy on request.

Please review the me+ enrollment terms prior to submitting your patient’s information.

Patient Consent Acknowledgement

By completing this form on behalf of you and your patient, you acknowledge the following:

Your and your patient’s privacy is important to us. Convatec will not share your patient’s or your personally identifiable information with an unrelated party without your and your patient’s permission. Please read our privacy policy where you can find detailed information on how we protect and use customer information; we can also provide you and you patient with a copy on request.

Please review the me+ enrollment terms prior to submitting your patient’s information.

Consent to Data Processing

*Your and your patient authorize Convatec to enroll them in the me+ program. The patient understands that the personal information submitted here will be used for the purposes of their membership. The use of your and your patient’s information may include contact by phone, email, text or mail from Convatec and its affiliates for coordination of products and services related to this program

Consent for Retail Referral

Your patient authorizes Convatec to identify and refer them to a designated Convatec retailer if they decide to order Convatec products. The patient also authorizes Convatec to disclose to their healthcare provider or to the providing manufacturer (1) their participation in the program (2) the samples or products ordered, and (3) any feedback provided regarding the program or such products and samples.

Consent to Marketing

Your patient authorizes Convatec and its affiliates to contact them through commercial electronic messages (emails, text), traditional mail or phone calls for the purpose of communicating promotional information (marketing messages) about Convatec products, services, news, and events.

Your and your patient can withdraw these authorizations at any time by contacting us by telephone at 1-800-422-8811, or by email at cic@convatec.com. The patient may also click on the ‘Unsubscribe’ link in the footer of the emails or text messages they may receive.

Enroll Your Patients in me+™ from Convatec

HCP me+ Enroll

Patient Information

Patient Information

HCP Information

HCP Information