Condom requests - Sexual Health Quarters

Request Free Condoms

Fields marked with an * are required

Please note: Condom donation stock is currently limited. We apologise for the inconvenience. If you require additional condoms, they are also available to purchase from our online shop.

The information provided on this form will be used to determine if your request is eligible for a donation. Priority will be given to target audiences as determined by the SHQ Strategic Plan.

Condom requests for demonstration or distribution in schools can only be filled if they are submitted by a staff member (e.g. teacher, nurse).
Name * Required
First Last
Organisation * Required
Address * Required
Street Address Address Line 2 City ZIP / Postal Code
State * Required
- I understand that these resources are available to organisations based in Western Australia only.
Email * Required
Phone
Title of event (If applicable)
Date of event (if applicable)
MM slash DD slash YYYY
Target Audience
Description of service/event * Required
SHQ staff may be able to attend your event. Please visit out Event Requests page for more information.
Number of participants
Number of condoms required (max quantity 100) * Required
Please enter a number from 0 to 100.
If you are running a larger event or ordering for multiple sites and require more than 50 condoms, please email [email protected] and a member of our team will contact you to discuss your request.
Are the Condoms for demonstration purposes* only? * Required
- Yes
- No
*USE OF CONDOMS FOR DEMONSTRATION PURPOSES ONLYSHQ can supply expired condoms (stock permitting) for demonstration purposes i.e. educational demonstrations in showing the correct technique for using condoms.If requesting condoms for demonstration please download and sign our condom liability form, and upload it to this form where indicated. No expired condoms can be supplied until this additional form has been received.
Upload completed liability form * Required
Max. file size: 128 MB.
Can you collect your order from SHQ in Northbridge? * Required
- Yes
- No
Please note: if you cannot collect, you will be asked to contribute to the cost of postage
Any additional information about your request?
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