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I would like to receive an ostomy product sample.
Street Address
City
State
Zip Code
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Phone Number
Fax Number
In order for us to send you the correct product sample, please provide the following information. (If necessary, the Hollister Consumer Programs Team may need to contact you to ensure you receive the correct product for your needs.)
I have a:
Colostomy
Ileostomy
Urostomy
Stoma Size
(inches or mm) I Don't Know
Does your stoma protrude
at least 1/2"?
Yes No
What ostomy products do
you currently use?
Hollister
ConvaTec
Coloplast
Other
What type of product do you use?
(Please indicate whether you use a one-piece product or a two-piece product.)
I use a one-piece product.
Pouch/Barrier Stock Number
I Don't Know
I use a two-piece product.
Barrier Stock Number
I Don't Know
Pouch Stock Number
I Don't Know
Which type of barrier
do you prefer?
Precut
Cut to Fit
Where do you purchase your ostomy supplies?
I Don't Know
Retailer Name
City
State
Zip Code
Please contact me, in the future, with new product information and other valuable updates.*
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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, 8:30 a.m. to 5:30 p.m. CST.
I have read and acknowledge the Privacy Statement.*
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