Safer-Sex Kit Request Form

Safer-Sex Kit Request Form

Corktown Health Center provides free Safer-Sex kits by mail customized to your needs!
Please note that this service is only available to residents of the State of Michigan
How did you hear about our Free Condoms by Mail program? *

Billboard Ad in Palmer Park Bus Ads Radio Dating App (Grindr, Jack'd, Scruff) Social Media (Facebook, Instagram) Mobile advertisement News coverage (Between the Lines, Newspaper, TV) Referral from another agency Corktown Health Center website Palm Cards with QR code
Name *

First Name Last Name
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age Group *
Type of Safer Sex Kit *

Latex Variety Pack Flavored only Non-Latex (Latex Allergy) Dental Dams Custom Mix Kit (Choose 10 items from below)
Build your custom Safer Sex kit from the items below. A custom Kit contains 10 total items. If you select more than 10, we will provide the first 10 selected.
Please note for privacy condoms will arrive in a plain brown envelope. Your email and the data on the order form will only be used internally and will not be shared with any third party.
Should be Empty: