Enroll today in Hollister Secure Start services

Enroll below or call 1.866.789.7574 to start receiving a lifetime of personalized support.

First Name:

Last Name:

Birthdate:

Address:

2nd Line Address Details:

City:

Province: Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nunavut Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon

Zip/Postal Code:

Email (if you don’t have an email address, click here)

Phone:

Phone Type: LandlineMobile

How do you prefer to be contacted? PhoneEmail

Preferred Language: English French

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

How long will you have your stoma? Permanent Temporary Unknown

When did you have your surgery?

Did a clinician assist you in filling out this form? Yes No

Assisting Clinician’s Name:

Assisting Clinician’s Facility/Agency:

Assisting Clinician’s Phone Number:

Assisting Clinician’s Email Address:

List Products/Additional Requests here:

For the purpose of enrolling in Secure Start services, a free end-user service program, and receiving the associated membership benefits, I consent to the processing of my name, address, contact information, gender, communication preference, health information, product information, third party information, transactional information, and request details by Hollister and 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 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 end-user services, or as part of a membership benefit, using the contact information (postal address, email, phone, & text) that I have provided. In some jurisdictions Hollister may also disclose my personal and health information to my healthcare professional, healthcare product supplier, health insurance provider, or other third parties as indicated in the respective Privacy Notice. Hollister reserves the right to change the end-user service program at any time.

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