Have questions?

Sexualhealth@nnph.org

775-328-6147

Condom Program

Full Name

First Name

Last Name

Mailing Address

Street Address

City

State

Zip

Phone Number

Email

Age Range

13-15

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50+

Race/ethnicity

White

African American/Black

Asian

Hawaiian/Pacific Islander

American Indian/Alaskan Native

Hispanic/Latino

Unknown

Decline

Sex at Birth

Male

Female

Current Gender

Male

Female

Transgender

Decline

Who do you have sex with

Males

Females

Person who injects drugs

Transgender

HIV Positive

Unknown HIV Status

Have you ever injected drugs?

Yes

No

HIV Status

HIV Positive

HIV Negative

Prefer not to answer

Unknown

If you are HIV negative, would you be interested in a medication to prevent HIV (PrEP)?

Yes

No

I would like to receive information about PrEP

How would you prefer to be contacted if we have questions about your request?

Phone Call

Text

E-mail

How did you hear about this program?

Friend/Relative

Social Media

Website

Healthcare Provider

Partner

Internet

The majority of condoms provided by WCHD are the ONE brand. Descriptions are available at: https://www.onecondoms.com/collections/condoms. Please note we offer a selection of these condom options that are listed below.

Which safer sex items would you like to try out?

Type(s) of Condom

Colored

Non-latex

Internal Condom (known as the Female/Reality condom)

Textured

Glow in the dark

Larger

Snugger

Ultra-Sensitive

Flavored

ONE Pleasure Plus

One Vanish

Amount Needed (Max 10 Total per Request )

Amount Needed (Max 5 Total per Request)

Extras

Lube

Dental Dams

Lube: Amount Needed (Max 5 per request)

Dental Dams: Amount Needed (Max 5 per request)

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