Order a C-Card

First Name

Surname

Date of Birth

Age

Address Line One

Address Line Two

Town

Postcode

Email

Contact Number

You must provide a valid telephone number in case we need to contact you about your order. We will only use these details to contact you about your order, we won't use them for marketing purposes.

Gender at birth Male Female Not known

Gender Identity Male (including trans male) Female (including trans female) Non-binary Prefer not to say

Sexual Orientation Heterosexual (Straight) Gay Lesbian Bisexual Unsure Prefer not to say

Which of the following best describes your ethnic group?

(please tick one selection)

Country of Birth

Have you used this service before?

Do you have a C-Card

Yes No

Please read and tick the following boxes to confirm you have read the below information. Your data

The information you provide within this form will be shared with Midlands Partnership NHS Foundation Trust. Your information will be used to create an electronic sexual health record which is confidential and not shared with other services, unless we have reason to believe you or someone else is at risk of harm and the information in this form is relevant to keeping you safe. If you would like more information relating to your rights and the Trust, visit https://www.mpft.nhs.uk/about-us/information-governance

By completing this form, you are giving us your permission to contact you by post (including posting out your items), telephone and email in relation to your C-Card online registration form, as well as any other sexual health services, as required.

I confirm I have read this

The information you provided

I understand that C-Card registration online is offered to people aged 16+ living in Leicester. I confirm that the information I have submitted is correct and accurate and that I am eligible for registration under these terms and conditions. I understand that if I am already registered with the scheme and have an active C-Card, I will be issued condom supply, not a new C-Card.

I confirm my information is accurate

More C-Card information

For more information on the C-Card scheme, you can visit leicestersexualhealth.nhs.uk/c-card , or call your local sexual health service, where you can find out things like your nearest registration and distribution venues.

I confirm I have read this

Sexual Health Service information

For more information on anything else to do with sexual health, like STI testing, contraception, emergency contraception and information and advice, please contact your local clinic. You can find details of your local service at https://leicestersexualhealth.nhs.uk/ .

I confirm I have read this

Healthy relationships

Everyone has the right to a relationship free from abuse. If you feel scared, worried or concerned about sex or relationships and would like to speak to a member of our team, please tick yes below. For more information on our support services, please visit: https://leicestersexualhealth.nhs.uk/other-support-services

Yes No

Condom Demonstration

I confirm I have watched the above video

How we will post your C-Card

Once an order is placed, it may not be possible for it to be cancelled

Your C-Card will be sent in plain packaging with no sexual health branding

Please allow up to 10 working days for your C-Card to arrive

If you would like to use your C Card to access a C Card condom pack, please find your nearest venue. leicestersexualhealth.nhs.uk/clinic-and-service-finder

Information about consent

The legal age for sex in the UK is 16, for everyone. Nobody under the age of 13 can consent to any form of sexual activity. Alcohol and drugs can also affect a person's capacity to consent.

I confirm I have read this