Hollister Secure Start Services: Clinician-Assisted Enrollment

Hollister Secure Start Services:
Clinician-Assisted Enrollment

Personalized Patient Support

Patients may have questions about their ostomy, how to care for their stoma, and how to keep living the life they want to live — but they don't have to figure it out on their own. Hollister Secure Start services offers FREE dedicated support for as long as needed, regardless of the brand of products used.

Enrolling is easy for patients and includes:

Personalized support from a Consumer Service Advisor
Product, supplier, and insurance information
Condition-specific information and access to community resources

If you have questions, call us at 1.888.808.7456.

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Patient's Email Address: (optional)

If you provide your email address, tracking will be enabled for this and future sample requests.

Phone Number:

Birthdate: (optional)

XX/XX/XXXX

Stoma Type:

Surgery Date:

XX/XX/XXXX

Assisting Healthcare Professional's Name:

Assisting Healthcare Professional's Facility/Agency:

Healthcare Professional's Phone Number:

Healthcare Professional's Email Address: (optional)

List Products/Additional Requests here: (optional)

If you leave this section blank, Secure Start services will send you a sample of our 2-piece soft convex ostomy pouch.

Do you need help placing your order?

Yes

Consumer Service Membership

I am facilitating enrollment of the named patient into Secure Start^SM Services and I acknowledge that I have informed them of the Service Consent Terms and Conditions and the patient consented.