Request Samples Esteem Body- Convatec

Complete this form to request samples of Esteem Body® with Leak Defense™

Have questions in the meantime? Call our Convatec me+ support team at 1-800-465-6302, Mon-Fri, 8am-6pm (ET) to speak with a nurse or product specialist. You may also email us directly at convatec.canada@convatec.com

*Required

Complete this form to request samples of Esteem Body® with Leak Defense™

Have questions in the meantime? Call our Convatec me+ support team at 1-800-465-6302, Mon-Fri, 8am-6pm (ET) to speak with a nurse or product specialist. You may also email us directly at convatec.canada@convatec.com

*Required

First Name*

Last Name*

Address Line 1*

Address Line 2

City*

Province*

Postal Code*

Country*

Telephone (Do not include spaces)*

Email Address*

Surgery Type*

What is the size (diameter) of the hole you have cut for your stoma?*

Stoma Type*

Is your stoma located near a hernia?*

Which type of skin barrier are you currently using?*

Which type of pouching system is your preference?* (Note that Esteem Body® is offered in a one-piece option only)

Which type of pouch are you interested in?*

Which pouch colour is your preference?*

Which brand are you currently using?*

Which accessories are you currently using?*

Adhesive remover spray/wipes

Appliance belt

Night drainage system

Skin barrier spray/wipes

Odour control

Paste/powder

Seal/barrier/strip

None of the above

Notes

How We Use Information

Treating your personal data with care is important to us. Please read our privacy policy where you can find detailed information on how we protect and use personal data.

How We Use Information

Treating your personal data with care is important to us. Please read our privacy policy where you can find detailed information on how we protect and use personal data.

Privacy Policy*

* I agree to the processing of my personal data (name, surname, email address) by Convatec for the purpose of completing my product sample request. I know that providing data is voluntary, but necessary for the Customer Relations Center product specialist or nurse to assess which product(s) best meet(s) my specific requirements.

Multiple or single choice

From time to time, we (Convatec) would like to send you commercial electronic messages (emails) for the purpose of communicating promotional information (marketing messages) about Convatec products, services, news, and events. By ticking the box, you consent to us emailing you for this purpose.

You can opt out of receiving marketing messages anytime by contacting us by telephone at 1-800-465-6302, or by email at convatec.canada@convatec.com. You may also click on the ‘Unsubscribe’ link in the footer of the emails you will receive.

Please note our calls come from number 1-800-465-6302 or as potential spam.

You can opt out of receiving marketing messages anytime by contacting us by telephone at 1-800-465-6302, or by email at convatec.canada@convatec.com. You may also click on the ‘Unsubscribe’ link in the footer of the emails you will receive.

Please note our calls come from number 1-800-465-6302 or as potential spam.

Request Samples of Esteem Body®

Convatec Product Samples

Complete this form to request samples of Esteem Body® with Leak Defense™

Complete this form to request samples of Esteem Body® with Leak Defense™

How We Use Information

How We Use Information