HCP me+ Enrollment Form

We are here...

... to make sure you don't have to figure it out alone. When you enroll in me+, you get all the valuable resources and support you need right at your fingertips.

Community

Inspiring stories and ideas from others living with an ostomy

Answers

An in-depth resource covering everything ostomy

Style

Clothes that conceal your ostomy pouch - and look great too

Community

Inspiring stories and ideas from others living with an ostomy

Healthcare Professional Resources

Enroll Your Patient in me+™

Provide your patients with an additional layer of support and care when you sign them up for me+.

With me+™, we surround your patients with the education, support and resources they need to feel stronger, more confident and ready for what's ahead. Our program is designed and customized to guide the right support at the right time at all stages of life.

Have questions? Contact the me+ concierge team at 1-877-585-0470 opt. 1 or email, concierge@convatec.com.

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First Name*

Last Name*

Email Address

Phone Number*

Country*

Comments/Special Instructions

Patient Consent Acknowledgement

You and your patient’s privacy is important to us. By submitting both your patients and your information, you both agree to ConvaTec’s privacy policy, available by clicking here.*

You and your patient authorizes ConvaTec and its affiliates to call, email, text or mail you information about ConvaTec’s products and services. If the patient would like to order ConvaTec products, they authorize ConvaTec to identify and transfer them to a designated ConvaTec retailer. Your patient may withdraw this authorization by calling or writing to us.*

By submitting this request, you confirm that (1) the Customer has authorized the disclosure of the requested personal information; (2) the Customer has requested that you submit this form on his or her behalf; (3) the Customer has agreed to the ConvaTec Privacy Statement; and (4) the Customer has agreed to the Authorization Transfer provision.*