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

Once your patient has chosen to enroll, please allow them to complete the form below. 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 Provider's Name:

Assisting Healthcare Provider's Facility/Agency:

Healthcare Provider's Phone Number:

Healthcare Provider'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 No

IMPORTANT:
To complete enrollment, your PATIENT must read the Privacy Statement and Enrollment information below, and your PATIENT must then check the box below to indicate agreement with privacy statement and consent to enroll and click "Submit".

Consumer Service Membership

For the purpose of enrolling in Secure Start services, a free consumer service program, and receiving the associated membership benefits, I consent to the processing of my personal identification, communication preference, health information, product information, third party information, transactional information, and request details by Hollister and its Group Companies (see link below) and its affiliated service company, where applicable. I understand that these services are free of charge, and there is no obligation to purchase anything to receive them. I understand that I am under no obligation to participate in any/ all of the applicable membership benefits, such as assistance identifying product supplier options, and receiving product samples and other complimentary items. I understand that Hollister, its Group Companies and affiliated product supplier, may communicate with me about consumer services, or as part of a membership benefit, using the contact information (postal address, email, phone, & sms text) that I have provided. Hollister may also share my personal and health information with my healthcare professional, doctor, healthcare product supplier, health insurance provider or other third parties as indicated in the data privacy notice. Hollister reserves the right to change the consumer service program at any time.

I agree to Consumer Service Membership (This checkbox is required)

Direct Marketing

For the purpose of receiving information about products, promotions, and other direct marketing campaigns, I consent to the collection and processing of my personal identification, communication preference, consumer health data [Information about my health-related conditions, treatment, diseases, or diagnoses, and request details, where applicable, by Hollister, which includes its Group Companies (see link below)]. I agree that Hollister, including its Group Companies, may use my consumer health data to tailor marketing communications specifically related to my health needs and interests. I understand that Hollister and its Group Companies may communicate with me about these topics, using the contact information (postal address, email, phone, & text) that I have provided.

I agree to Direct Marketing

Your consent is optional and you have the right to withdraw it at any time. To withdraw your consent or to make changes to your communication preferences, contact us at privacy@hollister.com. Such withdrawal only has future effect (i.e. the withdrawal of your consent has no effect on the lawfulness of the data processing and disclosures before the withdrawal was made).

For more details regarding Hollister and its Group Companies, please refer to our Group Companies Page. Please find further details regarding the processing of your personal data and your legal rights in our full Privacy Notice.