Acknowledgment

Hollister values patient choice. Hollister Secure Start services are patient-focused services, which patients can elect to enroll in via paper and web-based forms that Hollister Secure Start services has provided. Patients might request your help in submitting such forms to Hollister. In order to facilitate a patient’s enrollment, we request that you explain the service to them, receive their verbal consent to enroll, submit their enrollment, and then attempt to obtain their written consent, and if received, promptly send to Hollister Secure Start services. For Continence Care enrollments, we must receive written patient consent to process the enrollment.

• I have read and acknowledge this statement.