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Rooted Reproductive Support Project Request Form

Name

How did you hear about us?

Do you live in Wilson County, KS?

Do you live in Wilson County, KS?
A
B

Have you received products from us before?

Have you received products from us before?
A
B

What items are you in need of?

Prevention

Prevention

Period Products

Period Products

Medications

Medications

Trying to Conceive

Trying to Conceive

Postpartum Products

Postpartum Products

Is this a pick up or drop off?

Is this a pick up or drop off?
A
B

If a drop-off, what is the location of the drop-off?

Pick Up location is at 37 Century Parkway, Neodesha, KS. Please fill out the contact information below so we can arrange pick up details.

Contact Information :

Please share one preferred method of communication so we can coordinate pickup or drop-off.

Please share one preferred method of communication so we can coordinate pickup or drop-off.
A
B
C

After selecting one option, please enter your contact details in the field below.

Please allow 24-36 hours for follow up communication.
Rooted Reproductive Care Project of SEK is a community-powered mutual aid project and does not provide medical care, diagnosis, treatment, or medical advice. Any information provided is for educational purposes only. Individuals are responsible for following all manufacturer instructions and warnings for over-the-counter medications. For medical questions or concerns, consult a licensed healthcare professional.