Telehealth Landing Page Form

Request a me+™ Virtual Support Appointment

Simply complete the below form to request a virtual support appointment.

First Name*

Last Name*

Email Address*

Phone Number*

Phone Number Type*

Surgery Date*

Surgery Type*

Why are you requesting a telehealth appointment?*

What day(s) or time(s) will work best for you? (Select all that apply)

Monday

Mornings, 9a-12p

Tuesday

Afternoons, 12p-5p

Wednesday

Thursday

Friday

Your privacy is important to us. By submitting your information, you agree to ConvaTec's privacy policy, and you also 1) authorize ConvaTec to call, email, text or mail you information about ConvaTec's products and services; 2) if you would like to order ConvaTec's products, you authorize ConvaTec to identify and transfer you to a designated ConvaTec retailer; and 3) You may withdraw this authorization by calling or writing to us at cic@convatec.com or 1-800-422-8811..

I agree to the above statement.