Request a Sample Thank you for your interest in Hollister products. To request a free product sample, please submit the information below. If necessary, the Hollister Consumer Programs Team may need to contact you to confirm product sizing. Please provide all appropriate contact information. Requested Product(s)* [If requesting multiple product samples, please separate the stock numbers with a comma.] First Name* Last Name* Street Address* City* State* - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces America Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Zip Code* Daytime Phone Number* Email Address* Where do you purchase your ostomy supplies? Retailer Name City State - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces America Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Zip Code My insurance is: Medicare Medicaid Private Carrier I have a:* Colostomy Ileostomy Urostomy Not Sure Surgery Date* (Month/Day/Year - approximate) Hospital Name Hospital City Hospital State - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces America Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific My Stoma Size* (inches, mm or not sure) My stoma is:* (Select more than one.) Protruding Protruding more than 1/2" Retracted Round Flat Irregular Shape Not Sure What ostomy product do you currently use? Hollister ConvaTec Coloplast Other Barrier Stock Number Pouch Stock Number Which type of barrier do you prefer? (Select more than one.) Precut Cut-To-Fit Flat Convex What type of ostomy accessories are you using? Paste Barrier Rings Pouch Deodorants Other Accessories Stock Number Questions/Comments Please contact me, in the future, with new product information and other valuable updates.* Yes No Confirmation Code:*   Why do we ask for a confirmation code? Please enter the characters you see below into this box: + By submitting information online, you agree that such information will be governed by our Privacy Policy and Copyright/Disclaimer statement. PRIVACY STATEMENT Your privacy is important to Hollister Incorporated ("Hollister"). Hollister will not sell or rent customer information to others. Personal information collected by Hollister is used to contact customers about Hollister and its products and services and is only shared with other outside organizations (service providers) to help them contact customers on behalf of Hollister. If you no longer wish to receive such communications, you may "opt out" at any time by calling Hollister at 1.888.740.8999, Monday through Friday, 8:00 am - 5:00 pm (Central Standard Time). I have read and acknowledge the Privacy Statement.* * Indicates required field