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How did you learn about us? (optional) Friend Magizine Ostomy Nurse Pharmacy/DME Support Group Web Search Other
Have you previously ordered samples from us? Yes No
Please choose one of the followings I am a Healthcare Professional/Caregiver Supplier Patient Hospital
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Me The Patient
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 Colostomy Ileostomy Urostomy Urine
2.) Stoma Size/Shape: Round Oval
Diameter (inch): 1/2'' 5/8'' 3/4'' 7/8'' 1'' 1-1/8'' 1-1/4'' 1-3/8'' 1-1/2'' 1-5/8'' 1-3/4'' 1-7/8'' 2-1/8'' 2''
Height 1/2'' 5/8'' 3/4'' 7/8'' 1'' 1-1/8'' 1-1/4'' 1-3/8'' 1-1/2'' 1-5/8'' 1-3/4'' 1-7/8'' 2-1/8'' 2'' Width 1/2'' 5/8'' 3/4'' 7/8'' 1'' 1-1/8'' 1-1/4'' 1-3/8'' 1-1/2'' 1-5/8'' 1-3/4'' 1-7/8'' 2-1/8'' 2''
3.) Stoma Profile:
7.) Date of Surgery: [ dbl click inside or enter date as mm/dd/yyyy ]