Patient Forms → Binder Request Lifting up the voices in the LGBTQ+ community, near and far.

Binder Request Form

Over the last several years, HCAI has provided free chest binders to hundreds of LGBTQ+ youth – and we're here to help you, too. Request yours today by filling out the form below.

Learn more about Binder Do's and Don'ts

* Required field

Please note: Binders are only shipped to people over the age of 18.: *

Check here if you are over the age of 18.

Email Address: *

Your Information

First Name (as you wish it to appear on the mailed package): *

Last Name: *

Is your shipping address based in the US or abroad?: *

USUS territory (Puerto Rico, Guam, US Virgin Islands)Outside of the US

Your Size: *For more information and directions for sizing please click here.

Your Address

Please double check that you include your complete mailing address. For example:

123 East Main Street

Apartment 456

New York, NY 100001

United States

Street Address: *Please check your address above and make sure it is complete, i.e.: apartment or unit number, binder will not be shipping if the address is incomplete.

Address Line 2:

Address Line 3:

State/Province: *

City: *

Zip/Postal Code: *

Country: *

Phone Number: *

Do's & Don'ts: *

I acknowledge that I have read and understand the do's and dont's of binding.

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.