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Request Healthy Man Kit

Please complete the fields below and click the Submit button. A complimentary Texas Health Resources Health Man Kit will soon be sent to the indicated address.

Note: Offer valid for Texas residents only. Supplies limited.

* Indicates required information
First Name * 
Middle Initial 
Last Name * 
Street Address * 
Address 2 
City * 
State * 
Zip * 
Address Type * 
Home Phone 
Work Phone 
Cell Phone 
e-mail Address * 
Gender * 
Date of Birth (MM/DD/YYYY) 
Children in Household * 
Health Insurance? * 
Primary Care Physician * 
Preferred Texas Health Hospital * 
Note: Please enter authentication challenge words below and click Submit button only once.  
Authentication * 

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