Free Order Form

NATIVE HEALTH’s Integrated Health Outreach Program is now offering free condoms, At-Home HIV test kits, dental dams, and Narcan!

Read item descriptions here.

For questions, contact Madalyn at msisson@nachci.com or call (602) 279-5262 Ext. 14003.

Please fill out the form below to order.

New Order Form IHOP

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Which location are you picking up from?*
- NATIVE HEALTH Central
- NATIVE HEALTH Mesa
- NHW Community Health Center
Which item(s) are you requesting?*
- Condoms (12 count)
- FC2 Internal Condoms (3 count)
- Dental Dams (5 count)
- At-Home HIV Test Kit (1 count)
- Naloxone/Narcan (1 count, contains 2 single-dose nasal spray devices)
If choosing HIV Test Kit, a staff member will follow up via preferred contact method to record results and answer any questions.
If selecting condoms, which type of condoms would you like?
- Assorted latex
- Non-latex
- Magnum
Name*
First Last
Email*
Phone*
Address ZIP code*
ZIP / Postal Code
Select all that apply*
- Chicano
- Cuban
- Mexican
- Mexican American
- Puerto Rican
- Not Hispanic
- Other Hispanic or Latin Origin
- Decline to Specify
Select all that apply*
- American Indian/Alaskan Native
- Asian Indian
- Chinese
- Filipino
- Japanese
- Korean
- Vietnamese
- Other Asian
- Guamanian/Chamorro
- Native Hawaiian
- Samoan
- Other Pacific Islander
- Black/African American
- White
- Other Race, Not listed
- Decline to Specify
If selected American Indian/Alaskan Native, which tribe?

We are here to help

NATIVE HEALTH is here to provide high quality, patient-centered medical, dental, behavioral health, WIC and wellness programs when you need us.

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Name*
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Email*

NATIVE HEALTH received the HRSA Patient Centered Medical Home badge. Community Health Quality Recognition badges recognize Health Center Program awardees that have made notable quality improvement achievements.

NATIVE HEALTH Central

4041 North Central Ave., Bldg. C
Phoenix, Arizona 85012
P: (602) 279-5262
F: (602) 279-5390

NHW Community Health Center

8800 North 22nd Avenue
Phoenix, Arizona 85021
P: (602) 279-5262
F: (602) 279-5361

NATIVE HEALTH Mesa

777 West Southern Ave.
Mesa, AZ 85210
P: (602) 279-5262
F: (480) 264-5222

NATIVE HEALTH at Walupe Health Center

6725 South Priest Drive
Guadalupe, AZ 85283
P: (602) 279-5262

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