Personal Protection Package

First Name:*

Last Name:*

Email Address:*

Phone Number:*

Address:*

City:*

State:*

Zip Code:*

Age:*

You must be 18 or older to use this service.

Ethnicity:*

Hispanic Non-Hispanic Haitian

Race:*

Required Questions

Question #1: Using 2 condoms will make sure that I or my partner will not get HIV and other STIs (Sexually Transmitted Infections) as well preventing pregnancy?*

True False

Question #2: There is no such thing as a female condom, only a male condom exists! *

True False

Have you seen the "Getting 2 Zero" campaign ?*

Yes No

Would you like to receive dental dams ?:*

Yes No

Would you like to receive female condoms ?:*

Yes No

Would you like to receive non-latex condoms ? These condoms are for people who have allergies to latex.:*

Yes No

Disclaimer: The information obtained in this application will be used solely to keep a record of the people receiving the supplies from our office and will not be shared with anyone.

By checking this box, I affirm that I live in Miami-Dade County, I am an adult (18 or older), and I am making this request for myself *

The information obtained in this application will be used solely to keep a record of the people receiving the supplies from our office and will not be shared with anyone.