Condom Ordering Form

Terms of Use

By placing this order, I agree to each of the following:

All items ordered through this program must be provided FREE of charge.
All of these items will be distributed solely within Miami-Dade County.
The staff, volunteers and other agents of my organization may not knowingly furnish these items for re-distribution outside of Miami-Dade County.
I will cooperate with staff from the Florida Department of Health in Miami-Dade County Condom Program in evaluating this program.

: *
I Agree I Disagree

Your Contact Information

Do not complete this request form unless a Condom Distribution Application has already been submitted and you have received authorization to make Condom requests. You must specify below the e-mail address and organization address that was provided on the Condom Application.

You will receive a confirmation notice from The Florida Department of Health in Miami-Dade Condom Program after placing your request. If you have any further questions regarding this program, please contact Erika Coello at Erika.Coello@flhealth.gov. Thank you!

First Name *

Last Name *

Title

Organization *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Email Address *

Phone Number *

Phone Extension

Fax Number

Other Requests

Indicate your order on the form below. The quantity specified should be the number of cases you would like for each item.

Male Condoms
Female Condoms
Other Latex Barriers
Lubricants

NOTICE: We make no assurances that we have the itemized products in stock. We reserve the right to:

Deny any order in whole or in part;
Adjust the quantity of orders; and
Substitute items.

Please allow approximately 3-4 weeks for this order to be filled.

Male Condoms

ONE Legends (1,000 per case) *

Lifestyles SKYN (latex free, 1,000 per case) *

ONE Classic (1,000 per case) *

ONE Flavors (1,000 per case) *

Trojan ENZ (1,000 per case) *

Trojan Magnum (1,000 per case) *

Atlas Black (1,000 per case) *

Female Condoms

FC2 Female Condom (100 per bag) *

Other Latex Barriers

Sheer Glyde Dental Dams (100 per case) *

Lubricants

ONE Move (silicone-based, 500 per case) *

ONE Oasis (water-based, 500 per case) *

Enter Confirmation Number

Cancel