By checking this box, I confirm that in each instance where I verbally communicate patient consent regarding the ConvaTec Starter Kit™ Program to a ConvaTec representative, (1) I have reviewed the ConvaTec Starter Kit™ Program with the patient; and (2) he/she has agreed to enroll in the ConvaTec Starter Kit™ Program and to receive product samples, support literature, and related communications from ConvaTec.