Please fill out the form below and we will use your stoma characteristics and preferences to send the product most suitable for you.

First Name:

Last Name:

Birthdate:

Gender Male Female Prefer not to say

Address:

2nd Line Address Details:

City:

State/Province/Region

Zip/Postal Code:

Email Address:

Phone:

Phone Type: MobileLandline

Current Product Manufacturer: New User Dansac Other Manufacturer

Product Number/SKU

Do you currently use NovaLife TRE™ Ostomy Products? Yes No I don't know

What type of stoma do you have? Colostomy Ileostomy Urostomy Fistula Unknown

How long will you have your stoma? Temporary Permanent Unknown

When did you have your surgery?

What size is your stoma? (in mm) If you do not know, please enter 00

How would you describe your stoma? Protrudes/ has a spout Skin Level/ flush Retracted/ below the skin Prolapsed Unknown

Do you have a hernia? Yes No

What type of closure do you prefer? Drainable Closed

What accessories do you use? Rings or SealsBarrier ExtendersAdhesive Remover

For the purpose of processing, fulfilling, and communicating with me about the sample request I am requesting, I consent to the processing of my name, address, contact information, gender, age/birthday, communication preference, health information, product information, third-party information (authorized representatives), transactional information, and request details, where applicable, by Dansac, which includes its Group Companies. I further consent to the following methods of contact including postal address, email, phone, SMS, and other messaging services, as provided. I understand that Dansac, its Group Companies may communicate with me about my order, using the contact information that I have provided.

For the purpose of receiving information about products, promotions, and other direct marketing campaigns, I consent to the processing of my name, address, contact information, gender, communication preference, health information, and request details, where applicable, by Dansac, which includes its Group Companies. I further consent to the following methods of contact including postal address, email, phone, SMS and other messaging services, as provided. I understand that Dansac and its Group Companies may communicate with me about these topics, using the contact information that I have provided.

For the purpose of participating in Dansac’s feedback programs, such as surveys, product or service evaluations, and/or clinical trial activities, I consent to Dansac’s processing of my name, address, contact information, age/birthday, gender, and health information, as necessary to ensure the suitability of my participation (such as mobility, type of surgery, product usage, skin conditions, lifestyle), where applicable, for this purpose. I further consent to the following methods of contact including postal address, email, phone, SMS and other messaging services, as provided. As used herein, “Dansac” refers to Dansac and its Group Companies.

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