First Name
Last Name
Email
*
example@example.com
Gender Pronouns
She/her/hers
He/Him/His
They/Them
Another Pronoun
Date of Birth
*
-
Month
-
Day
Year
Date
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Can we send you text messages?
*
Yes
No
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Next
Race/Ethnicity
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Native Hawaiian or Other Pacific Islander
White
Don't Know
Decline to answer
Gender Identity
*
Male
Female
Transgender Female / Transgender Woman
Transgender Male /Transgender Man
Gender-neutral/Non-binary/Two-spirited
Genderqueer/Gender Fluid
Decline to answer
Another gender
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Do you have an allergy to latex and need a latex-free condom?
*
Yes
No
Do you need any additional information or resources (such as PrEP)?
*
Yes
No
Would you like a packaged delivered monthly for the next 3 months?
Yes
No thank you
Would you like to receive an At-Home test kit?
Yes
No
Submit
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