Condom requests - Sexual Health Quarters

Request Free Condoms

Fields marked with an * are required

Please note: Condom donation stock is currently limited. 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

Free resources are only available to organisations based in Western Australia
Email * Required
Phone
Title of event (If applicable)
Date of event (if applicable) - must be mm/dd/yyyy format
Date Format: MM slash DD slash YYYY
Target Audience
Description of service/event * Required
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 100 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 ONLY SHQ can supply expired condoms (stock permitting) for demonstration purposes i.e. educational demonstrations in showing the correct technique for using condoms. After completing this form, SHQ will require you to sign a condom liability form, no expired condoms can be disseminated until this additional form has been finalised.
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?