Get free condoms. Complete this form if you are interested in getting condoms delivered or want to update your subscription information. "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.Which of the following would you like to do?* I want to start a subscription I want to renew my subscription I want to make updates to my subscription I want to cancel my subscription Start or Renew a SubscriptionComplete the below sections to either start or renew a subscription.County of Residence*Choose oneGwinnettNewtonRockdaleFirst Name*Last Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email* Your Phone*Preferred method of contact?* Email Telephone Which race or ethnicity best describes you?*Select AnswerAlaskan Native or Native AmericanAsianBlack or African American, Not Hispanic or LatinoPacific Islander or Hawaiian NativeWhite, Not Hispanic or LatinoHispanic or LatinoMultiracialPrefer not to sayGender?*Select AnswerMale - Assigned at Birth and Identify as MaleFemale - Assigned at Birth and Identify as FemaleTransgender Female to MaleTransgender Male to FemaleNon-binaryOtherPrefer not to sayAge Range* 16-19 20-34 35-49 50+ Prefer not to say Which type of condoms would you like?* Variety pack condoms Non-latex condoms XL condoms Make Updates to a SubscriptionComplete the below sections to cmake updates to your subscription.County of Residence*Please enter the county of residence currently listed on the subscription.Choose oneGwinnettNewtonRockdaleFirst Name*Please enter the name currently used on the subscription.Last Name*Please enter the name currently used on the subscription.Address*Please enter the address currently used on the subscription. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Which information do you want us to update?*Please check all that apply. County of Residence Address Name Email Phone Number Contact Preferences Age Range Gender Type of Condoms Received County of Residence*Choose oneGwinnettNewtonRockdaleFirst Name*Last Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Email* Your Phone*Preferred method of contact?* Email Telephone Gender?*Select AnswerMale - Assigned at Birth and Identify as MaleFemale - Assigned at Birth and Identify as FemaleTransgender Female to MaleTransgender Male to FemaleNon-binaryOtherPrefer not to sayAge Range* 16-19 20-34 35-49 50+ Prefer not to say Which type of condoms would you like?* Variety pack condoms Non-latex condoms XL condoms Cancel a SubscriptionComplete the below sections to cancel your subscription.County of Residence*Please enter the county of residence currently listed on the subscription.Choose oneGwinnettNewtonRockdaleFirst Name*Please enter the name currently used on the subscription.Last Name*Please enter the name currently used on the subscription.Address*Please enter the address currently used on the subscription. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you share the condom supply you receive with anyone?* Yes No Who do you share the condom supply you receive with?*Check all that apply. Friend Roommate Family Member Other If you selected other, please specify who you share the condom supply with.*Is the number of condoms received too many?* Yes, it's too many. No, I need more. No, the amount I receive now is perfect. About how many condoms do you use each month?*If you indicated that you ordered condoms for you AND also partner(s) or friends, only tell us the amount of condoms that you personally expect to use each month. Select AnswerNone1-4 per month5-10 per month11-20 per monthMore than 20 per monthOtherI am not sureI prefer not to sayI believe the condom subscription program is an effective initiative to reduce STIs (sexually transmitted infections) such as HIV.*Please select either agree or disagree. I agree I disagree Have you talked about the condom subscription program with others such as family, partners, and/or friends?* Yes No I prefer not to say Would you like someone to contact you to schedule an HIV test?*Testing is FREE and confidential.Select AnswerYesNoAre you interested in receiving information about upcoming events?*Select AnswerYesNoYour Email Your PhonePreferred method of contact? Email Telephone Surge Community SurveyCommunity feedback is important to us! Take a few moments to answer the following questions so we can better serve you.Who will use, or who currently uses, the condoms you receive?*Check all that apply. Me Friend Roommate Family Member Other If you selected other, please specify who will use, or currently uses, the condoms you receive.*About how many condoms will you, or do you currently, use each month?*If you indicated that you ordered condoms for you AND also partner(s) or friends, only tell us the amount of condoms that you personally expect to use each month. Select AnswerNone1-4 per month5-10 per month11-20 per monthMore than 20 per monthI am not sureI prefer not to sayOtherIf you selected other, please specify.*What is your sexual orientation? Check all that apply.* Asexual Bisexual Gay Lesbian Pansexual Straight Not listed I prefer not to say If your sexual orientation is not listed, please specify.*Have you ever heard of PrEP?*Pre-Exposure Prophylaxis (PrEP) is a medicine taken to prevent getting HIV. PrEP is highly effective for preventing HIV when taken as prescribed. Yes No I am not sure I prefer not to say Are you currently using PrEP?* Yes No I am not sure I prefer not to say Have you ever heard of PEP?*Post-exposure prophylaxis (PEP) is a medicine taken to prevent HIV after a possible exposure. PEP must be started within 72 hours of possible exposure to HIV. Yes No I don't know I prefer not to say Have you ever used PEP?* Yes No I am not sure I prefer not to say When was your last HIV test?* I have never been tested Within the last 6-12 months More than one year ago I prefer not to say How did you hear about this subscription service?*Select AnswerFriendInternet SearchCommunity EventSocial MediaHealth Department StaffHealthcare ProviderSurge websitePoster or flyerOtherHave you talked about the condom subscription program with others such as family, partners, and/or friends?* Yes No I prefer not to say I believe the condom subscription program is an effective initiative to reduce STIs (sexually transmitted infections) such as HIV.*Please select either agree or disagree. I agree I disagree Would you like someone to contact you to schedule an HIV test?*Testing is FREE and confidential.Select AnswerYesNoAre you interested in receiving information about upcoming events?*Select AnswerYesNo Call Us 678-442-6897 Email Us info@surgegnr.com Visit Us 455 Grayson Highway, Suite 500, Lawrenceville, GA 30045