Clinician Form - Coloplast Canada
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Thank you for your interest in trying Coloplast Products

We are glad your clinician has referred you to us. Please fill the form below to access product sampling. Once you fill the form, a Coloplast Care Advisor will be in touch with you to discuss your product needs and help you find a product that is right for you.

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Privacy statement
Coloplast Canada has created this privacy statement in order to demonstrate our firm commitment to privacy. 

Coloplast will respect the privacy of your personal information and protect the confidentiality of sensitive information. Information provided to us by you or by a third party, will be used to process your orders and for general administrative record-keeping purposes. The information may also be used or shared with a third party if required by law or in order to provide you with information related to Coloplast's products, services and wellness education. You may be contacted by Coloplast, its agents, group companies, contractors, supply or service providers (“Coloplast Agents") by telephone, email, letter, or other means of communication but only for the purposes referred to above. In such cases Coloplast will ensure that the Coloplast Agent will comply with applicable privacy legislation as well as this Privacy Statement. 

By submitting your personal information to us you consent to Coloplast, and any Coloplast Agents, to store and use this information in order to provide information and updates on Coloplast's products and services and to allow Coloplast to contact you by email and/or ordinary mail and/or telephone, including recording of such phone calls – and, if needed, to clarify your sample requirements. 

If you no longer wish to receive communication from Coloplast or would like to request that any personal data in Coloplast’s possession be deleted, please contact Coloplast’s local Consumer Support Services by email with your request that all communication has to be discontinued


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