Ostomy Supply Request Form
Our Ostomy Supply Closet is available to help provide un-insured Sothern California residents secure ostomy supplies.

Ostomy supply pick up:
Once per month in Torrance, CA pick up date and time will be updated the first week of each month.
Schedule can be found here:


Please submit this form and one of our volunteers will contact you within 3-5 days.

About our Ostomy Supply Closet:
  • Our Supply Closet is run by non-medical volunteers who generously donate their time and energy.
  • Due to the volume of requests and the limited number of volunteers we're unable to accommodate emergency ostomy supply requests or make deliveries.
  • This form must be completed for each month you request supplies
  • We're a small nonprofit  group. We don't have an office, storefront or clinic.
  • Requested supplies are picked up once a month per the schedule linked above: 
  • Our volunteers will make 3 attempts to contact you by phone &/or email to make arrangements for you to pick up requested supplies.
  • A $25 donation is suggested (not required). These donations are used to cover storage facility costs for our Supply Closet

Please complete the application below
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Email *
Name *
Email

 *
Phone
(One of our volunteers will contact you within 3-5 days)
**Please ensure your phone's mailbox is set up and not full in case we miss you. We'll leave a message for you to call us back :)
 *
Zip code *
Is this your first time requesting supplies?
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Have you attended a local Support Meeting? (not required)
Clear selection
What kind of ostomy do you have?
 *
(Not Required) If you're requesting specific products, please include:
Brand (Coloplast, Convatec, Hollister), Product type (bag, wafer/flange, etc.), Item number
What size is your stoma in mm or inches? 
There should be a measuring tool in every box or bags. Or, you can tell us what size you cut the hole in your wafer or flange.
One size does NOT fit all.  This information is required to ensure you receive ostomy supplies that will work for you!

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Captionless Image
What type of bag?

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Type of wafer/flange

 *
Specific Brand

 *
Do you need Accessories?

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I understand:
1.  This ostomy supply closet is made possible by a handful of hardworking volunteers and donations.  Any unkindness toward our volunteers will not be tolerated.
            We're volunteers trying to help :)
2.  We'll make 3 attempts to contact you to arrange for you to pick-up requested ostomy supplies in Torrance, CA. 
 *
Required
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