Safe Sex Order Form

Last updated: March 20, 2023

Please complete the required fields below to request your kit today. All fields are required.

Kits can also be mailed directly to you. To request a mailed kit, call 410-222-7382. You may leave a voice mail, requesting a kit. You must provide your name, phone number and County address in the voice mail. Please indicate if you would like the kit to be sent in a blank envelope, which does not contain Department of Health information. Allow two weeks for delivery.

Please note: All requests are confidential.

The Safe Sex Kit Includes:

Information on HIV/STD 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 condom, dental dams, and lubricants

Safe Sex Kit Order Form

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email Address *

Phone *

I would like the kit to be sent in a blank envelope (without any Department of Health information). *

Yes

Other Special Requests

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

How did you hear about the Safe Sex Kit?

Has this kit been easy to order?

Yes

No (Why?)No (Why?)

Additional Comments

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Questions about
COVID or mpox?

410-222-7256

Questions about COVID or mpox?

410-222-7256

Questions about
COVID or mpox?