West Central Health District

Mail-Order Condoms

Free condoms are available to be mailed directly to your home as long as long as you are 18 years or older. You must live in the state of Georgia and reside within the West Central Health District. The counties included are as follows: Chattahoochee, Clay, Crisp, Dooly, Harris, Macon, Marion, Muscogee, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, Taylor, and Webster Counties.

LIMITATIONS:

~ You must live in one of the counties listed above.
~ You must be over the age of 18.
~ Condom packs are limited to those listed in survey.
~ Each person is allowed one order per month.
~Orders will be mailed weekly.
~ Please contact us at (706) 321-6426 for questions or concerns.

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* 1. NAME

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* 2. MAILING ADDRESS

P.O. BOX:

STREET ADDRESS:

APT #:

CITY:

STATE:

ZIP CODE:

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* 3. CONTACT INFORMATION

PHONE NUMBER:

EMAIL:

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* 4. SELECT COUNTY OF RESIDENCE:

CHATTAHOOCHEE

CLAY

CRISP

DOOLY

HARRIS

MACON

MARION

MUSCOGEE

QUITMAN

RANDOLPH

SCHLEY

STEWART

SUMTER

TALBOT

TAYLOR

WEBSTER

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* 5. GENDER EXPRESSION:

MALE

FEMALE

TRANS

GENDER FLUID

PREFER NOT TO SAY

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* 6. AGE:

18-24

25-34

35-44

45-54

55-64

65+

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* 7. RACE/ ETHNIC IDENTITY:

AMERICAN INDIAN/ ALASKAN NATIVE

AFRICAN AMERICAN/ BLACK

ASIAN

CAUCASIAN/ WHITE

HISPANIC/LatinX

NATIVE HAWAIIAN/ PACIFIC ISLANDER

OTHER

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* 8. SELECT DSIRED CONDOM PACK : (Choose only 1 pack)

SNUGGER FIT PACK

REGULAR PACK

LARGE PACK

X-LARGE PACK

NON-LATEX PACK

FLAVORED PACK for oral sex

INTERNAL PACK (FEMALE CONDOMS)

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* 9. HOW DID YOU HEAR ABOUT THE MAIL-ORDER CONDOM PROGRAM?

SOCIAL MEDIA (FACEBOOK, INSTAGRAM, TWITTER)

PALM CARD/ FLYER

FRIEND

HEALTH DEPARTMENT (Website or In person)

OTHER (please describe)

Other (please specify)

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* 10. Would you be interested in receiving an At-Home STD test?

Yes