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Health Housing and Human Services

Condom Request Form 

Condom Request Form 

If you would like to request condoms and lubricant for your organization, please fill out this form and click the submit button below.  

If you are an individual looking for free condoms, please visit the State of Oregon Condom Delivery Program. 

 

Organization Information

Are you a: 
What population(s) does your agency serve? (Check all that apply.) 

Condoms Request

Each condom package contains 144 condoms. Please indicate the number of packages of each type of condom you would like below.  
specialty latex condoms such as colored, textured and flavored condoms — variety of styles not guaranteed

Lubricant Request

Each lubricant package contains 100 lubricants. Please indicate the number of packages of each type of lubricant you would like below.  
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