Thank you for your interest in Coloplast^® Care

Coloplast® Care is a patient support and education program that provides you with reliable information so that you can better manage your own care and experience a full life. Led by a team of Care Advisors and supported by nurse-validated education, Coloplast Care offers:
• Individualized support led by patient-focused Consumer Care Advisors specializing in continence
• Access to free samples
• Routine self-assessments to identify and address concerns

Please provide the following information to enroll in Coloplast Care.

Your Personal Information

First name:*

Last name:*

Address:

City:

State:

Zip code:

Email address:

By providing an email address, you consent to the receipt of personalized support through Coloplast® Care online.

Phone number:*

What type of product(s) are you currently using?Intermittent catheter
Male external catheter
Leg/night bags
Foley catheter

Your Clinician's Information

Clinician's First Name:*

Clinician's Last Name:*

Clinic/Center Name:*

Clinic/Center Address

City

State

Zip Code

Terms of Enrollment

Terms of Enrollment

I accept the Terms of Enrollment

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Thank you for your interest in Coloplast^® Care

Your Personal Information

Your Clinician's Information

Terms of Enrollment

Thank you for your order

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Thank you for your interest in Coloplast® Care

Your Personal Information

Your Clinician's Information

Terms of Enrollment

Thank you for your order

Thank you for your interest in Coloplast^® Care