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.

Ileostomy Colostomy Urostomy

Flush Recessed Protruding

Clamp Closure Microseal Closure Velcro Closure

Irritation Adherence Other

With Filter Without Filter

Flat Convex Deep Convex

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

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(where you would like the sample to be shipped)

Address 1 *

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Address 2

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

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Phone number 2

Best Time to Call if Necessary *

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Message

City *

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State *

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Country *

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Zip Code*

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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...