Sexually Transmitted Infections (STIs) Medications and Condoms Order Form

These medications are to be used to treat suspected or confirmed cases of gonorrhea, chlamydia or syphilis.

* = Required

Health Care Provider Information

* Office name

* Practitioner name

* Contact name

* Email

* Phone xxx-xxx-xxxx

* Fax xxx-xxx-xxxx

Treatment Information

For other treatment options, call 905-688-3817 ext. 7223.

Gonorrhea treatment
Preferred treatment	Ceftriaxone 250 mg IM Azithromycin 1 g PO
Chlamydia treatment
Preferred treatment	Azithromycin 1 g PO single dose OR Doxycycline 100 mg PO BID for seven days
Syphilis treatment
Primary, secondary, early latent less than one year duration	Bicillin* L-A (penicillin G benzathine) 2.4 million U IM in a single dose
Late latent, more than one year of indeterminate duration	Bicillin* L-A (penicillin G benzathine) 2.4 million U IM once a week for three consecutive weeks

Order Information

Medication	Treatment dose	Doses
Azithromycin, 250 mg tabs	1 g (four tabs / dose)	(max 15)
Doxycycline, 100 mg tabs	14 tabs - one tab PO BID for seven days	(max 5)
Ceftriaxone, two 250 mg vials	500 mg dose (includes lidocaine preferred diluent and sterile water for lidocaine allergy)	(max 3)
Benzathine penicillin G. 2.4 million U IM Medication will only be released with a positive lab result	Single dose *Orders including benzathine penicillin G. require a consultation with a sexual health nurse. Call 905-688-3817 or 1-800-263-5757 Monday to Friday, 8:30 a.m. to 4:30 p.m. and ask to speak to a nurse.	(max 3)
Condoms	Plain lubricated Bags of 100 condoms	(max 2)

Delivery Information

* Receive order by Pick-up at the St. Catharines Sexual Health Centre, 277 Welland Ave. Your order will be ready for pick-up in three business days.
Benthazine penicillin G. delivery
Include with monthly vaccine delivery

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.