Enroll in Coloplast Care

 

Coloplast Care is a program provided to you free of charge. We help make life easier for people, like yourself, who are living with intimate healthcare needs, and the Healthcare Professionals that support you by offering many different educational tools.

 

Enroll in Coloplast Care using the form below. Alternatively, you can enroll in one of in the following ways: 

  • Call- contact a Coloplast Care Specialist at 1-888-226-6362
  • Fax- send the enrollment form to 1-800-501-8533


Please provide the following information:
Is this a cell phone or a land line? *

I currently use the following product(s):





Coloplast Confirmation of Consent


 

*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 unsubscribe-us@coloplast.com  to request that communication be discontinued.

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