Nu-Hope Sample Request

Note: We send free samples with free USPS shipping to the US and Canada only. For all other countries, samples are free, but there will be a charge for shipping and handling.

★ = Required field

How did you learn about us? (optional)

I am a Healthcare Professional/Caregiver
Supplier
Patient
Hospital


Shipping Information (Ship to):








Apt/Unit/Floor #   (optional)


Zip/Postal Code (Enter zip code for city and state lookup.)

City

County

State/Province

About your Ostomy:

The following information is Very Important in helping us determine the best pouch to suit your needs. Please complete each field to the best of your knowledge.

1.) Ostomy Type

Output Consistency

2.) Stoma Size/Shape:
Round
Oval


Diameter (inch):




3.) Stoma Profile:

Recessed what?
Recessed
Flush
Low Profile
Protruding

4.) Skin Condition:

5.) Is there a hernia present?
Yes
No

6.) Is a belt worn?
Yes
No


7.) Date of Surgery: [ double click inside or enter date as MM/DD/YYYY ]

Shield Preference?


Stoma Opening




Would you like a catalog?
Yes