Free Condoms and HIV Self-Test Kit Request Form

The Georgia Department of Public Health Southwest Health District is offering free condoms and/or HIV self-testing kits 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 and at least 17 years of age to receive a test kit. To request a free condoms and/or a HIV self-test kit, 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 are limited to one shipment per person each month.
  • Orders will be shipped and filled once per week.
For additional resources visit our website: http://www.southwestgeorgiapublichealth.org/hiv_aids_program/ 
FOR ADDITIONAL QUESTIONS CALL: (229) 638-6428

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* 1. First and Last Name

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* 2. What is your address?

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* 4. What is your phone number?

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* 5. What is your email address?

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* 6. What is your age?

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* 7. Race/Ethnicity 

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* 8. Sex at birth?

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* 9. Current Gender Identity?

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* 10. What is your sexual orientation?

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

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* 12. Please send me the following:

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* 13. How would you like to receive your condoms and/or test kit?

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* 14. How did you hear about this service?

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