Request a Trial
Discover ConvaTec Moldable Technology™ Skin Barriers! Please complete the form below to receive your free trial.*
First Name *
Last Name *
Shipping Address *
City *
State *
Zip Code *
Date of Birth *
Phone *
Email Address

Date of Surgery *



 
Surgery Type *

 
Stoma Size *


 
Do you require Convexity? *
X

You may require a convex skin barrier if your stoma does not protrude.
 
Pouch Type *


 
Filter Preferred *
 
Enter Promo Code *

Optional Fields:
Product Currently Wearing


 
Current System Type
 
Condition





Product Numbers (You can find these on your product box)
Skin Barrier/Wafer Number
Pouch Number
One-Piece Product Number

Privacy Statement

As a ConvaTec customer, your privacy is important to us. ConvaTec will not sell, rent or give away personally identifiable information you provide to us, i.e. information from which you can be identified, to any unrelated third party without your written permission except to an actual or prospective successor to a part or all of our business, or as required by law, or legal or regulatory process.

Information that identifies you may be used by ConvaTec, its agents, subcontractors, affiliates, or other service providers to process your request(s), to contact you about products, services, promotions or programs, or other information that may be of interest to you, for treatment of the patient's conditions or to contact you to participate in market research.

If you no longer wish to receive such communications from ConvaTec, you may "opt out" by sending an email to CIC@convatec.com , or by calling ConvaTec any time at 1-800-345-8011, Monday through Thursday, 8:30 a.m. to 8:00 p.m. ET, Friday, 8:30 a.m. to 6:00 p.m. ET, or Saturday, 10:00 a.m. to 2:00 p.m. ET, or by writing to ConvaTec at: One Healthcare Way, Lakewood, NJ 08701, Attention: Data Privacy. This statement may be updated from time to time.
I have read the Privacy Statement and agree to its terms.

* Any product received as a free sample is for own-use, is not for resale, and cannot be billed to any insurance company, patient, or third party payor, including, but not limited to Medicare and Medicaid.