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.
(please tick one selection)
Do you have a C-Card
All of our C-Card packs contain 6 condoms and 3 lube sachets. Please select an option below:
If you are ordering dental dams, your pack will be made up of 4 dental dams, 2 regular condoms and 3 lube sachets.
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 understand that C-Card registration online is offered to people aged 16+ living in South Staffordshire. 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.
For more information on the C-Card scheme, you can visit openclinic.org.uk/ccard , or call your local sexual health service, where you can find out things like your nearest registration and distribution venues.
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://openclinic.org.uk .
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.
Once an order is placed, it may not be possible for it to be cancelled
Your C-Card and/or condom pack will be sent in plain packaging with no sexual health branding
Please allow up to 10 working days for your condom pack to arrive
If you would like more condoms, please use your C-Card and visit openclinic.org.uk/ccard to find your nearest distribution venue
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.
