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Samples for StomaBags

Samples

Note: We sell anywhere. We send free samples with free shipping only to the US and Canada. For all other countries, samples are free, but there might be a charge for shipping.

Please write the following information:

Brand *

Are you an out-of-pocket buyer? *
Yes    No

Date of Surgery: *

This field is required

Date of Birth: *

This field is required

Language: *
English Spanish
Other:
Type of ostomy *
(to determine the correct product)
Ileostomy Colostomy Urostomy
Requesting Product #:

What product are you currently using?:

Additional comments:
Note: If necessary, the Hollister Service Team may contact you directly regarding this product sample request.

Year and/or Date of Surgery *
This field is required

Type of Stoma*
Flush Recessed Protruding
Pouch Preference:*
1 Piece 2 Piece

Select:*
Drainable Closed End
Pouch Closure:*
Clamp Closure Microseal Closure Velcro Closure

Pouch Color Preference:*
Opaque Transparent
Sample Request
Either enter Coloplast product numbers:

Or check product options below

Is your stoma above the skin level? *
Yes   No

Do you wear a belt? *
Yes   No

Primary Insurance Provider: *

This field is required

Preferred Supplier (optional):

Secondary Insurance Provider: *

This field is required

Stoma size *
(please tell us the approximate diameter)
This field is required
Shape of Stoma *
Oval Round
Problems *
Irritation Adherence Other

Please Explain
Pouch Filter Preference:*
With Filter Without Filter
Barrier Type:*
Flat Convex Deep Convex
Barrier Preference:*
Cut To Fit Precut

Do you have any skin folds, creases, or dips around the stoma? *
Yes   No

Brand Preference
SenSura® Mio
SenSura®
Assura®
Convexity
Flat
Soft Convex
Convex Ligh
Deep Convex
System
One-Piece
Two-Piece Flez
Two-Piece Click
Cut Style
Cut-to-fit
Pre-cut
Pouch Closure
Closed
Drainable
Urostomy
Barrier Type
Extended Wear
Standar Wear
Filter
Yes
No
Accessories
Belt XL Belt
Elastic Barrier Strip
Y-shape
Curved
Straigh
Lubricating Deodorant
Protective Seal
Paste
Strip Paste
Powder
Prep
Name *

This field is required

Email *

This field is required
Please use a well format email.

Mailing address *
(where you would like the sample to be shipped)
Address 1 *

This field is required

Address 2

Phone number 1 *
(where you can be reached with any questions)

This field is required
Phone number 2

Best Time to Call if Necessary *

This field is required

Message

City *

This field is required

State *

This field is required

Country *

This field is required

Zip Code*

This field is required

Please verify your identity by clicking the checkbox below:
This field is required

Why put this?
This Captcha is used to avoid spam. It ensures that you are not a machine.

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*Conditions Apply

Brand *
Are you an out-of-pocket buyer? * Yes No
Date of Surgery: * This field is required Date of Birth: * This field is required Language: * English Spanish Other: Type of ostomy * (to determine the correct product) Ileostomy Colostomy Urostomy Requesting Product #: What product are you currently using?: Additional comments: Note: If necessary, the Hollister Service Team may contact you directly regarding this product sample request. Year and/or Date of Surgery * This field is required Type of Stoma* Flush Recessed Protruding Pouch Preference:* 1 Piece 2 Piece Select:* Drainable Closed End Pouch Closure:* Clamp Closure Microseal Closure Velcro Closure Pouch Color Preference:* Opaque Transparent Sample Request Either enter Coloplast product numbers: Or check product options below Is your stoma above the skin level? * Yes No Do you wear a belt? * Yes No	Primary Insurance Provider: * This field is required Preferred Supplier (optional): Secondary Insurance Provider: * This field is required Stoma size * (please tell us the approximate diameter) This field is required Shape of Stoma * Oval Round Problems * Irritation Adherence Other Please Explain Pouch Filter Preference:* With Filter Without Filter Barrier Type:* Flat Convex Deep Convex Barrier Preference:* Cut To Fit Precut Do you have any skin folds, creases, or dips around the stoma? * Yes No
Brand Preference SenSura® Mio SenSura® Assura® Convexity Flat Soft Convex Convex Ligh Deep Convex System One-Piece Two-Piece Flez Two-Piece Click Cut Style Cut-to-fit Pre-cut	Pouch Closure Closed Drainable Urostomy Barrier Type Extended Wear Standar Wear Filter Yes No Accessories Belt XL Belt Elastic Barrier Strip Y-shape Curved Straigh Lubricating Deodorant Protective Seal Paste Strip Paste Powder Prep
Name * This field is required	Email * This field is required Please use a well format email.
Mailing address * (where you would like the sample to be shipped) Address 1 * This field is required Address 2 Phone number 1 * (where you can be reached with any questions) This field is required Phone number 2 Best Time to Call if Necessary * This field is required Message	City * This field is required State * This field is required Country * This field is required Zip Code* This field is required Please verify your identity by clicking the checkbox below: This field is required Why put this? This Captcha is used to avoid spam. It ensures that you are not a machine. SEND Sending email...