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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*
Zip Code*
Daytime Phone Number*
Email Address*

Where do you purchase your ostomy supplies?
Retailer Name
City
State
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
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
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