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Fill out this form to receive free condoms in the mail

Each order ships with 8 condoms in total. You may choose multiple types, but the total quantity mailed will be 8 condoms. Each person can request up to two condom packages per month.

Please note: This service is currently only available for PENNSYLVANIA RESIDENTS.

First Name*

Last Name*

Address*

Address - Suite/Apt/Lot/Etc (optional)

City*

Zip / Postal Code*

How did you hear about us?*

Email (optional)

Select Condom Type(s)*

Classic/Regular

Extra Large

Flavored Condoms (Currently OUT OF STOCK)

FC2s "Universal Condoms" / Female Condoms - *** FC2s are available in limited quantities. Please type ‘I'd like to request FC2s’ in the Notes section. Let us know if you've used them before, and let us know the Quantity you'd like sent (1-4).

Gender Identity*

Male, Cisgender

Female, Cisgender

Non Binary

Transgender Male

Transgender Female

Prefer Not to Answer

Self Describe

Race*

White

Black/African American

Asian

Latinx

American Indian/Alaskan Native

Native Hawaiian/Pacific Islander

Prefer Not to Answer

Self Describe

Notes / Special Requests (Optional)

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Josh Shapiro, Governor

Debra L. Bogen, Secretary of Health

This project is funded, in part, under a contract with the Pennsylvania Department of Health. Basic data for use in this study were supplied by the Pennsylvania Department of Health, Harrisburg, Pennsylvania. The Department specifically disclaims responsibility for any analyses, interpretations or conclusions.

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