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Nu-Hope Laboratories, Inc.

Hernia/Ostomy Belt Worksheet

*** THIS IS NOT AN ORDER FORM ***

Thank you for using our Hernia/Ostomy worksheet. This worksheet will help us determine the catalog number for your hernia/ostomy belt. You can then use this catalog number to place an order with your DME provider. Sorry, we do not sell to the public. Please do your best to complete every item on the worksheet. If you have any questions, feel free to contact us at beltinfo@nu-hope.com or 800-899-5017. When you click the submit button, you’ll receive a confirmation email which will include the information you provided for your records. Please allow up to 15 minutes for this email to arrive and don’t forget to check your spam folder. We will review your information by the end of the next business day and then email you with the appropriate catalog number. If we have any questions we’ll contact you.

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1) Belt Style Nu-Form Style for support of non-reducible hernia  Click here for more info     Original Flat Panel for pouch/support hernia prevention & small bulge flattening  Click here for more info

2) Belt Fabric Ventilated Cool Comfort®

Regular Solid Elastic

3) Belt Width (Nu-Form Style)  3"   4"   5"   6"   7"   8"   9"  OTHER "   (Original Flat Panel)  3"   4"   6"   9"  OTHER "

4) Belt Size Girth measurement -    Standing "   Lying (supine)  "   Small    Medium    Large    X-Large    XX-Large    Click here for more info

5) Stoma Location Right Side                    Left Side

6) Belt Hole Size If you know your belt hole size, please select it in the drop down menu. Sizes market with an asterisk are "custom" sizes for the Original Flat Panel belts. Please select 2"* 2-1/8" 2-1/4" 2-3/8" 2-1/2"* 2-5/8" 2-3/4" 2-7/8" 3" 3-1/8" 3-1/4" 3-3/8"* 3-1/2"* 3-3/4" 4”* 4-1/2"* Med Oval Lrg Oval XL Oval 2-7/8" x 3-3/8"* NO HOLE       If Unknown     Please provide the following:     Pouch Manufacturer Please select Coloplast Convatec Cymed Hollister Marlen Other If Other, Please specify:          One pc  Pouch#           Two pc  Flange#             Pouch#

7) Opening Placement (Vertically within the width - Click here for more info) Standard Placements     Nu-Form Style 3” thru 6" have a centered opening   7" thru 9" have the opening 1-1/2" from the bottom   Original Flat Panel 3" and 4" have a centered opening   6" thru 9" have the opening 1" from the bottom   Custom Hole Placement   To help us determine the placement of the opening, please provide the measurement from the bottom of the hernia to center of stoma "   8) Additional Requirements Prolapse Strap (-P), Auxilliary Belt, etc.               Enter the code shown