Free condoms by post

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Do you need condoms?

We provide a FREE condom postal service to people living in Worcestershire. If you live in Herefordshire, please visit the Sexual Health Services 4 Herefordshire website.

Please complete the request form below for condoms via post:

Your Information

Note: Questions marked by * are mandatory

Have you previously attended a Worcestershire Sexual Health Clinic?

Yes
No
Unknown

*This is a mandatory field. First Name:

*This is a mandatory field. Last name:

Previous Names:

Please call me:

*This is a mandatory field. Date of Birth:

Gender at Birth

Male
Female

I Identify as:

My pronouns are:

*This is a mandatory field. Country of birth/origin:

*This is a mandatory field. GP Practice:

*This is a mandatory field. Can we contact your doctor?

Yes
No
N/A

*This is a mandatory field. Home address including postcode (please note this is a postal service, contact will be made by post):

*This is a mandatory field. Contact/Phone number:

What is your preferred way for us to contact you? Please tick all that apply

Phone/Mobile
Text
Voicemail

Email Address:

	Yes	No	N/A
We may contact you by email for some feedback. Would this be ok?
*This is a mandatory field. Do you consider yourself to have a disability?

If yes, what type of disability? Please describe/detail here:

*This is a mandatory field. Do you require additional communication support?

Yes
No
N/A

I need:

Communication Support E.g. Hearing Loop, Lip reading,
A Communication Professional E.g. Sign language Interpreter
Information in a specific format E.g. Requires Braille, Information in 20-point sans serif font

Other Assistance: Please Detail:

*This is a mandatory field. Do you have a Latex allergy

Yes
No
N/A

Free condoms by post

Search the Herefordshire and Worcestershire Health and Care NHS Trust website

Do you need condoms?

Please complete the request form below for condoms via post:

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