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Home
About
HIV Testing
HIV+ Care
Prevention
PrEP Information
>
PrEP FAQ's
PrEP Referral Information
ACA Enrollment
Work With Us!
Volunteer
Board Members
Sponsors
DONATE
Events
Tap Gala
FAQ
Resources
Free Condoms!
Condom Distribution Sites
Distributor Condom Orders
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YOUR CART
Please fill out the below form to request Prevention Supplies.
*
Indicates required field
Name - Please note that we will only send out condoms if you put your first AND Last (Full) Name
*
First
Last
MUST put first AND FULL last name. **Just the first letter will result in your request being denied.
Address - Required if Mailing -- We Will ONLY Mail to Addresses Located in the state of KANSAS
*
Line 1
Line 2
City
State
Zip Code
Country
Please put street/PO Box, City, State and Zip Code in boxes below.
Phone Number
*
Email
*
Choose Delivery Option
*
Priority Mail
In Office Pick-Up
Priority Mail with No Return Address
Regular Latex Condoms
*
0
5
10
20
Non-Latex Condoms - PLEASE READ: ONLY ORDER if you ARE ALLERGIC TO LATEX!!! If you Order NON-LATEX condoms, we will NOT send out any other type of condom with your order.
*
0
3
5
6
Extra Large Condoms
*
0
3
5
10
Flavored Condoms - For ORAL SEX ONLY
*
0
3
5
8
10
Lubricants
*
0
5
6
10
Oral/Dental Dams - For Oral Sex
*
0
1
3
5
Female Condoms
*
0
1
3
5
Key Chain
*
1
2
3
5
8
10
Please put amounts needed, any comments or special requests below. Large Orders will be referred to our Outreach Department for business and requests for Condom DIspensers.
*
Name - By Typing this name you are stating that you are the above person and you are requesting these items in good faith. Impersonating another individual or requesting items for another person is strictly illegal. The IP addresses of those impersonating another individual will be given to local law enforcement.
*
First
Last
Submit
