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Order Ostomy Samples 

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Every ostomate is unique. A product that works for one individual may not work for the next. People with an ostomy often try several products before finding the perfect match. Coloplast can assist you in finding the right product through our sample fulfillment program.

To place an order for a free sample in the USA, complete the form below.  You may also order by phone by calling 1-888-726-7872 or send an email to samples@coloplast.com and a Coloplast Consumer Care Specialist will be able to assist you.

Nurses can also extend their care for a lifetime by enrolling new ostomy patients in the Coloplast Care continuum program.
 
First Name:* 
Last Name:* 
Address:* 
City:* 
State:* 
Zip Code:* 
Phone Number:* 
Email Address:
Date of initial ostomy surgery:
Surgery Type:* 
Stoma Size (inches):
Coloplast Product Code (if known, then submit request):
What type of barrier do you prefer?:
How would you describe the convexity of your stoma?:
What type of adhesive(s) would you like to try?:
What Coloplast system are you interested in?:
What product(s) would you like to sample? (Check all that apply):
List other product here:
What pouch color do you prefer?:
What ostomy accessories would you like to sample? (Check all that apply):
Which ostomy product are you currently wearing?:
What is the name of the ostomy product you are currently wearing?:
At what hospital was your ostomy surgery performed?:
What is your WOC Nurses Name?:
Please provide WOC Nurse contact information (phone or email):
Comments:
*Coloplast cares about your privacy and complies with HIPAA requirements. Coloplast will not sell, rent, or give away your personal information without your permission except where: (1) required by law; or (2) used by Coloplast, its agents, affiliates, contractors, or service or supply providers, to provide you with information by telephone or other methods, about Coloplast products, services, and wellness education. Coloplast may change this privacy statement from time to time. If you do not wish to continue to receive communication from Coloplast, you may opt out by contacting Coloplast at 1-888-726-7872 or email samples@coloplast.com. If this form has been completed by a healthcare professional, the healthcare professional acknowledges that he/she has read the above Privacy Statement to the patient.
*Acknowledgement of Patient Privacy:* 
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Our corporate HQ
1-800-533-0464

Quick contact
1-800-533-0464