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Condom Request Form

Fill out this confidential form, and we will mail you free condoms in an unmarked envelope.
At this time, ICHD is only able to mail condoms to addresses within Ingham County or the city of Lansing.

Condoms / Protective Products Requested


What is your current gender identity?

Do you think of yourself as?

By checking this box, I am certify that I live Lansing or Ingham County. I am making this request for myself and agree these condoms will be used for personal use between consenting individuals and will not be sold.