Request a sample of Convatec Moldable TechnologyTM. 

Please complete this brief form to request your free sample. Have questions? Call the Convatec me+™ team at 1-800-422-8811.
 

 
First Name*
 
 
Last Name*
 
 
Email Address*
 
 
Phone Number*
 
 
Phone Number Type*
 
 
Address Line 1*
 
 
Address Line 2
 
 
City*
 
 
State*
 
 
Zip Code*
 
 
Surgery Date*
 
 
Surgery Type*
 
 
Preferred Retailer*
 
 
 
 
 
Data Usage Consent*
 
 
I understand that the personal information submitted here will be used for the purpose of processing my sample request. This may include contact by phone, email, text or mail from Convatec and its affiliates for coordination of products and services related to my sample request.* 
 
 
 
Consent to transfer Info if needed
 
 
I authorize Convatec to identify and refer me to a designated Convatec retailer if I decide to order Convatec products. I also authorize Convatec to disclose to my healthcare provider or to the providing manufacturer (1) my request for samples, (2) the samples or products ordered, and (3) any feedback provided regarding such products and samples. 
 
 
 
Consent to marketing
 
 
I authorize Convatec and its affiliates to contact me through commercial electronic messages (emails, text), traditional mail or phone calls for the purpose of communicating promotional information (marketing messages) about products, services, news, and events.