Order your free ostomy samples

For individuals with an ostomy - please fill out the form below.

First name:*

Last name:*

Address:*

City:*

Zip code:*

State:*

Email:*

Phone number:*

Is this a cell phone or a land line? *Cell Phone
Land line

Who makes the ostomy product you are currently using? (e.g. Coloplast)

Date of ostomy surgery:

Coloplast Confirmation of Consent

I agree that Coloplast may use, process, and store the information I have entered, including my sensitive health data, to provide product information, as well as education and support as necessary. If applicable, the information may also be shared with a health care provider or medical equipment company to help order supplies, or with Coloplast’s affiliated companies, who may reach out regarding products and related supplies. Coloplast may reach out by phone, including to a cell phone if I provide that number, by text message, e-mail, or mail. Consent may be withdrawn at any time by e-mailing privacyrequests@coloplast.com. I acknowledge and agree that I have read and agree to the Coloplast Declaration of Consent

contactUsBysendUsEmail

Do you have any questions about Coloplast ostomy products?

If you have questions about Coloplast ostomy products, please contact us by phone at 1-855-605-7588 or by email at samples@coloplast.com

Headline

Order your free ostomy samples

For individuals with an ostomy - please fill out the form below.

Coloplast Confirmation of Consent

Do you have any questions about Coloplast ostomy products?

Need help choosing the right ostomy pouch?

Thank you for your order