Order Form

Please use this form to order condoms to be delivered to you by post. Our condoms are posted out to you monthly and contain either 6, 12, or 18 condoms and optional sachets of lube.

We can only give condoms and lube to "most at risk" groups. Please check the eligibility criteria for your area. We cannot send condoms outside of the areas that we cover.

We check the legitimacy of all new orders. Where an order does not meet the criteria of our service, it will not be processed, and notification will not be sent of this. Please do not misuse this service as it costs the time and resources of a charitable organisation. Thank you. 

The information that you give on this form is confidential. This means that we will not give out details that identify you to anyone outside Yorkshire MESMAC unless you have agreed for us to do so or if there is serious or urgent danger to you or anyone else. Please see our confidentiality statement for more information.

We may need to check your address is correct or confirm you still wish to receive the condom packs. You don't need to supply the email address however we have no way of checking any missing details otherwise and may not be able to send them out.

We need this information to make sure you are within our funding area. It will not be used for any other purpose.

Please write in the format dd/mm/yyyy.

Please note we will occasionally send out a request for you to re-confirm that you still want condoms and lube sent to your address.

Please remember to check the eligibility criteria on the "condoms and lube" page before you order. In some locations we are only able to supply condoms to men who have sex with men and young LGB&T* people.

Yorkshire MESMAC privacy statement

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Click here to cancel your condoms

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