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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.

* Required field

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

Your Information

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

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.
Do's & Don'ts: *

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