Sexual Health Supply Order Request Form

Sexual Health Supply Order Request Form
- Free, sexual health supply packet you can request to be mailed to you! Please allow 2 weeks for packet to arrive to submitted mailing address
- Packet will include at least 6 condoms, 2 lubricate packets, and information on condom use and testing resources.
- Our funding for these supplies come from monies awarded to Brown County Public Health (BCPH) by WI Dept. of Health Services Communicable Disease grant & American Rescue Plan Act.
Person Requesting Sexual Health Supplies

* Person requesting these sexual health supplies does have to be the person who will be receiving these supplies
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about this?*

Coaster QR codePoster QR codeBrowsing Brown County Public Health's websiteFriend/ Partner/AcquaintanceOther
If other, please include below*
Please read statements below and check all boxes*

By checking this box, I understand that this packet will be mailed through the US postal service, and I verify this is a valid address I provided. In addition, I understand that Brown County Health & Human Services- Public Health Division is not responsible for the package or its contents, which included but not limited to damage for package and/or contents, if this packet is seized or opened by an individual(s) that it is not addressed, etc.By checking this box, I understand that I may not get the requested for sexual health items fulfilled due to a fixed amount of supplies Brown County Public Health is able to secure. Vivent Health does have a limited, custom online health store that folks are able to order from for free sexual health supplies as well. https://depot.viventhealth.org/
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Sexual Health Supply Order Request Form

Person Requesting Sexual Health Supplies