JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
B!llikens for Reproductive Justice Safer Sex Supplies order
Complete this order to receive free safer sex supplies placed in your BSC mailbox (or another location if need be)! Everything is completely free and all information is confidential.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
What is your name?
*
Your answer
What is a way we contact you if there are any issues with the order?
*
Your answer
What is your SLU MSC? (If this doesn't work for us, let us know a different way we can get your product to you!)
*
Your answer
How many external condoms ("traditional" condoms, a barrier method that covers the tip and shaft of a penis)?
3
5
7
None
Clear selection
Do you require latex-free condoms?
Yes
No
Clear selection
How many internal condoms (placed inside the vagina or anus)?
2
3
4
None
Clear selection
How many dental dams (latex sheet, best for vaginal oral sex or anal sex to protect against STIs)?
2
3
4
None
Clear selection
How many lube packets?
2
3
4
None
Clear selection
Please leave a comment if you have a concern about pick up, have any questions, have special circumstances that need different product numbers, or otherwise need assistance in connecting to reproductive and sexual health resources.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
