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FREE Safer Sex Supplies Order Form

Please complete this form to order safer sex supplies from Hazen Center for Integrated Care. Orders will be picked up at the Prevention and Outreach Services office: 124B in the basement of the Seymour Union

  • Name Name *
  • My gender identity is: *
    My gender identity is:
  • My sexual orientation is: *
    My sexual orientation is:
  • My racial identity is: *
    My racial identity is:
  • I have a latex allergy and require latex-free products: *
    I have a latex allergy and require latex-free products:
  • I would like to request which of the following safer-sex supplies: *
    I would like to request which of the following safer-sex supplies:
  • I am an RA and this order is for my residence hall and not for my personal use?
    I am an RA and this order is for my residence hall and not for my personal use?
  • All orders require a minimum of one business day notice. If ordered after hours or on a weekend, expect a potential delay.

    I would like to pick up my order from the POS office at which time? *
    All orders require a minimum of one business day notice. If ordered after hours or on a weekend, expect a potential delay.

    I would like to pick up my order from the POS office at which time?
  • I would like to receive an email with information about STI/HIV testing services? *
    I would like to receive an email with information about STI/HIV testing services?
  • I would like to receive an email about Pre-Exposure Prophylaxis (PrEP).

    PrEP is a once daily oral medication designed for people at risk for HIV. It is proven to be highly effective for preventing the spread of HIV. *
    I would like to receive an email about Pre-Exposure Prophylaxis (PrEP).

    PrEP is a once daily oral medication designed for people at risk for HIV. It is proven to be highly effective for preventing the spread of HIV.
  • I would like to receive text notifcations when my condom order is ready to pick up? *
    I would like to receive text notifcations when my condom order is ready to pick up?
  • Cell-Phone Number (I understand that standard data usage charges may apply) Cell-Phone Number (I understand that standard data usage charges may apply) * - -
  • Draw or Type
    I understand this is a legal representation of my signature. Clear
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