Female Hygiene - Request Form
PLEASE READ THIS FORM. THIS FORM IS FOR LOCAL RESIDENTS ONLY (IF YOU LIVE IN OR AROUND BANDERA COUNTY TEXAS). NO OUT OF STATE REQUESTS PLEASE!!! OUR PICKUP LOCATION IS 11746 PARK ROAD 37 LAKEHILLS TX and this is a PICKUP SERVICE, NO DELIVERY OR SHIPPING AVAILABLE.
I have read the above and agree to follow the rules. I am not entitled to these services nor will I be able to utilize them if I don’t follow the rules. I also understand that Out Of The Way Community, Out Of The Way Cafe are no longer liable after pickup.
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Yes I understand.
No I do not understand
DO YOU LIVE IN OUR COMMUNITY? This service is ONLY available to residents in or around Bandera county, Texas.
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Yes I do.
No I do not.
Have you received birth control from us before?
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Yes I have.
No I have not.
A release of liability waiver will need to be signed in order to receive any form of Birth Control. This is a free service and we are aiming to provide, what we feel are basic necessities for women, by connecting directly with the companies to provide them to our community… at no cost. Any specific questions or concerns relating to the birth control should be taken up with the companies directly or your primary care physician. We are not doctors and these do not require a prescription. We are not responsible for any side effects. Please consult a doctor before using. Do you understand?
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Yes I do.
No I do not.
Your Information
This form must be filled out entirely.
Full Name
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First Name
Last Name
Birthdate
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number. This is how we contact via TEXT for pickup time / day (usually a Thursday).
Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which item(s) do you need?
Tampons
Pads
Panty Liners
Plan B
Opill Birth Control (3 month supply)
Pregnancy Test
Period Pack
IF YOU DO NOT LIVE IN OR AROUND BANDERA COUNTY TEXAS THIS IS NOT FOR YOU!
This service is ONLY available in Texas. WE DO NOT SHIP or send money!!
Submit
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