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Sample request

Do you want to request a sample? Please complete the form below or call 0031 (0)165-551226 and receive a free sample pack.

* = required field

By clicking on this box I realize that I am sharing personal health data to help EuroTec te send me a sample that matches my current system. If you want to know how we treat your personal data? Please look at our privacy policy.

I have a: (*)

Colostomy (solid stool)
Ileostomy (fluid stool)
Urostomy (urine)

The diameter of the stoma is ... (mm) (*)
 
Shape of the stoma (*)
Circular
Oval
 

I prefer a... (*)

1-piece system
2-piece system
Closed pouch for solid stool
Drainable pouch for fluid stool
Accessories namely...

My current flange size (with a 2-piece system) is ... (mm)
 
I now use ... (*)
A smooth adhesive
A convex adhesive
 

Currently I am using...

BBraun
Coloplast
Convatec
Dansac
Eakin
EuroTec
Hollister
Laprolan
Marlen
Welland
For Life
 

To be able to send you the sample, please complete the form below. We may need to contact you to ensure we send the product that matches your need, so we would be gratefull if you could provide your phone number or an email address.

 
Please fill in the form below completely Our customer service department will shortly be in touch with you..
Sir Madam
 (*)

Initial(s) (*)

Name (*)

Address (*)

Post/ZIP code (*)

City (*)

Country (*)

Phone number

E-mail address

Do you have any questions or comments?

How we use information Treating your personal data with care is important to us. Please read our privacy policy where you can find detailed information on how we use your personal data.

Yes I would like to receive regular updates on ConvaTec's products for ostomy care & services & news or events.

From time to time,  we would like to keep you informed about new products that are being developed, programs that could help you improve you quality of live, peer-to -peer feedback, or other information we think could be relevant to you as an ostomate. We will keep you informed you by e-mail, mail, post or telephone.


If you do not want to be contacted anymore, you can unsubscribe at any moment by contacting us at 0031 (0)165-551226 of by sending an email to info@eurotec.nl

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