Free Condoms Request Form

The Georgia Department of Public Health Southwest Health District is offering free condoms to residences of the following counties: Baker, Calhoun, Colquitt, Decatur, Dougherty, Early, Grady, Lee, Miller, Mitchell, Seminole, Terrell, Thomas, and Worth. Recipients must be at least 16 years of age to receive condoms. To request free condoms, please fill out the form below. 
 
LIMITATIONS DO APPLY TO THIS PROGRAM
  • Prevention supplies will only be sent to people living in the counties listed above. 
  • Orders will only be sent to people over the age of consent (16 years old).
  • Orders will be filled with assorted brands.
  • Orders are limited to one shipment per person each month.
  • Orders will be shipped and filled once per week.
For additional resources visit our website: https://swhealthdistrict.org/index.php/infectious-disease-2/#hiv
FOR ADDITIONAL QUESTIONS CALL: (229) 638-6428

Question Title

* 1. First and Last Name

Question Title

* 2. What is your address?

Question Title

* 3. What county do you live in?

Question Title

* 4. What is your phone number?

Question Title

* 5. What is your email address?

Question Title

* 6. What is your age?

Question Title

* 7. Race/Ethnicity 

Question Title

* 8. Sex at birth?

Question Title

* 9. Current Gender Identity?

Question Title

* 10. What is your sexual orientation?

Question Title

* 11. What type of condom package would you like to receive?

Question Title

* 12. Please send me the following:

Question Title

* 13. How would you like to receive your condoms?

Question Title

* 14. How did you hear about this service?

T