PREVENTION AT HOME Survey

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

1.First and Last Name(Required.)

2.What is your address?

Street Address

Apartment/Lot Number

City

State

Zip Code

3.What county do you live in?(Required.)

4.What is your phone number?(Required.)

5.What is your email address?(Required.)

8.Sex at birth?(Required.)

Male

Female

Other

10.What is your sexual orientation?(Required.)

Heterosexual (straight)

Homosexual (gay)

Bisexual

Other (please specify)

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

Assorted Regular (10-15 standard sized condoms and lube)

Assorted Large (10-15 large sized condoms and lube)

Assorted Non-Latex (10-15 non-latex condoms and lube)

Assorted Dental Dams (10-15 assorted flavored dental dams and lube)

12.How did you hear about this service?(Required.)