Order Form

Name * Email address

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.

First line of address (including the house or flat number and street name) * Second line of address Who do you pay your council tax to? *

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

Town * Postcode * Date of birth *

Please write in the format dd/mm/yyyy.

What condom size do you want? * How many condoms would you like in your postal order? *

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.

Do you want lube to be included in your order? (we will include the same number of sachets as condoms requested, please note we are unable to supply specialist lube such as silicone-based lube) * What is your gender? * If other, please specify Is this the gender you were assigned with at birth? What is your ethnic background? * If you feel that none of the above reflects your ethnic background, please specify... What is your Country of Origin? * What is your sexual orientation? *

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.

If Other, please specify Who do you have sex with? * Do you sell sex? What makes you potentially exposed to HIV? Are you happy to receive information from us regarding Yorkshire MESMAC services? * I have read and understood the Yorkshire MESMAC privacy statement and agree to the use of my data in line with this policy *