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 ParkBus AdsRadioDating App (Grindr, Jack'd, Scruff)Social Media (Facebook, Instagram)Mobile advertisementNews coverage (Between the Lines, Newspaper, TV)Referral from another agencyCorktown Health Center websitePalm Cards with QR code
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

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

Latex Variety PackFlavored onlyNon-Latex (Latex Allergy)Dental DamsCustom 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: