To begin your Care sign-up, complete a few simple questions below:

How long have you had your stoma?

What type of stoma do you have?

When did you last see your stoma care nurse?

Where do you go for help with your stoma?

When you seek help, are you able to get your issues resolved?

Who supplies your stoma care products?

How much stock do you like to keep at home, so you don't run out?

If offered, would you want to see a stoma care nurse to discuss your challenges?

By providing your personal information on this form, you are consenting to Coloplast using it for administration and analysis purposes.
We will share this information with healthcare professionals and other companies needed to deliver your products or if required by law.
We assure you, your personal information won't be passed on to any 3rd parties for marketing purposes however we may wish to contact you for customer satisfaction and research purposes.
From time to time we do let our customers know of new products or services which may be of interest by phone, email or post
By submitting your information to us, you consent to us contacting you in this way unless you have indicated that you would prefer for us not to contact you by ticking the box below. Please do not contact me by:


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