Enroll today in Hollister Secure Start services

Enroll below or call 1.800.263.7421 to start receiving individualized support during your catheterization journey.

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

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Phone Type: LandlineMobile

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Preferred Language: English French

What is the reason you are using catheters? BPH Cancer Endometriosis Mitrofanoff Multiple Sclerosis Spina Bifida Spinal Cord Injury Other

How long will you be using catheters? More than 6 months Less than 6 months

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

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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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