Sexually Transmitted Infections Medications and Condoms Order Form

Health Care Provider Information

* Office Name

* Practitioner Name

* Contact Name

* Email

* Phone xxx-xxx-xxxx

* Fax xxx-xxx-xxxx

Treatment Information

Gonorrhea Treatment
Single Dose	Ceftriaxone 250 mg IM Azithromycin 1 g PO
Chlamydia Treatment
First Line	Azithromycin 1 g PO single dose OR Doxycycline 100 mg PO BID for 7 days
Syphilis Treatment
Primary, Secondary, Early Latent less than 1 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 (4 tabs / dose)	(max 15)
Doxycycline, 100 mg tabs	14 tabs - 1 tab PO BID X 7 days	(max 5)
Ceftriaxone, 250 mg vial	Single dose - 1 g (includes Lidocaine Preferred Diluent and Sterile Water for Lidocaine allergy)	(max 5)
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 request 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 in 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.