Secure Start Enrollment Canada

Enroll today in Hollister Secure Start services

You may have questions about your ostomy, how to care for your stoma, and how to keep living the life you want to live — but you don't have to figure it out on your own. Hollister Secure Start services offers FREE dedicated support for as long as you need it, regardless of the brand of products you use.

Enrolling is easy and includes:

Finding the right products
Providing product information and condition-specific education
Finding local resources like Retailers and Clinicians
Product usage care tips

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

CLINICIAN-ASSISTED ENROLLMENT
Once your patient has chosen to enroll, please allow them to complete the form below.

First Name:

Last Name:

Street Address:

City:

Province:

Postal Code:

Email Address:

Phone Number:

(XXX) XXX-XXXX

Birth Date (optional):

XX/XX/XXXX

Preferred Language:

Stoma Type:

Stoma Duration:

Surgery Date:

XX/XX/XXXX

Did a clinician assist you in filling out this form? If yes, please answer all questions below. Yes No

Assisting Clinician's Name:

Assisting Clinician's Facility/Agency:

Clinician's Phone Number:

Clinician's Email Address:

List Products/Additional Requests here: (optional)

To complete enrollment, your PATIENT must read the Privacy Statement and Enrollment Information below, and your PATIENT must then check the box below to indicate agreement with privacy statement and consent to enroll and click "Submit".

Privacy Statement:

Privacy is important to Hollister Limited (Hollister). Hollister will not sell, rent, disclose or distribute any personal information without your consent except as permitted or required by law. Personal information collected by Hollister (information that can identify you such as your name, address, telephone number, gender, age, and personal health information) may be used by Hollister and its affiliates and business partners such as clinicians on behalf of Hollister for the provision of Hollister products, service (including participation in Hollister Secure Start Service and general customer service), and for marketing and data collection and management purposes. Hollister uses reasonable contractual or other means to require its business partners to protect personal information to a level comparable to that provided by Hollister. Hollister and its affiliates and business partners will keep your personal information private, confidential and secure and in accordance with all applicable federal and provincial privacy legislation. Your personal information may be collected, processed and stored by Hollister, its affliates or business partners in the United States of America (US), where it will be subject to US laws which may require disclosure of your personal information to the US government authorities. If you do not wish to be contacted or do not wish to receive information from Hollister, you can opt out by mail, email securestartcanada@hollister.com or call Secure Start at 1.866.789.7574. If you do not specify that you do not wish to be contacted, Hollister may contact you with information regarding our products, news and/or updates. You may, at any time, access and review your personal information held by Hollister, require any necessary amendments to correct or update it, and withdraw your consent to our collection, use and disclosure of your personal information, subject to any contractual or other legal requirements and reasonable notice. As this Privacy Policy may be revised from time to time, you should access and review it regularly to obtain the current version. By continuing to provide personal information or use Hollister products or services, you accept any such changes.

Enrollment:

Hollister Secure Start services are designed to support people as they live their lives with ostomy or bladder management issues. These services are free of charge, and there is no obligation to purchase anything to receive them. Product samples are provided for trial use by the patient and cannot be resold or billed. There is no obligation to accept samples or participate in insurance-matching to identify supplier options. Hollister reserves the right to change Secure Start services at any time.

I agree to the privacy statement and hereby consent to enroll in Hollister Secure Start services.

North America

Latin America

Europe

Asia/Pacific

AnchorFast SlimFit

CeraPlus™ Product Selector

VaPro™ Intermittent Catheters

Environmental Responsibility

Enroll today in Hollister Secure Start services