Free Safe Sex Kit Order Form | Anne Arundel County Health Department

Thank you for your interest in the Safe Sex Kit. In order to help the Department of Health serve our community’s needs better, please take the CONFIDENTIAL and ANONYMOUS survey below. The information and data collected in this survey will NOT be linked to the name, address and other contact information collected on the Safe Sex Kit request form. The information collected on this survey will be used for anonymous data purposes only.

The Safe Sex Kit Includes:

Information on HIV/STI facts and HIV testing sites
Condom Pal Case, which holds two condoms (great for purses and pockets)
A variety of condoms, e.g., male condoms, female condoms and dental dam

Orders are for Anne Arundel County Residents Only

First

Last

Phone

Street Address

City/Town

State/Province

ZIP/Postal Code

What is Your Age?

10 - 15

16 - 18

18+

Would you like the kit to be sent in a blank envelope (without any Department of Health information)?

Yes

Other Special Requests

How did you hear about the Safe Sex Kit?

Additional Comments

Has this kit been easy to order?

Yes

I certify that the information above is accurate and that I am the individual requesting the kit. I also certify that the contents of the kit will be used for the purpose of HIV/STD education and prevention.

Yes