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Sexually Transmitted Infections 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

Treatment Information

Gonorrhea Treatment
Single DoseCeftriaxone 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

MedicationTreatment DoseDoses
Chlamydia
First Line

Azithromycin 1 g (4 tabs/dose)

OR

Doxycycline 100 mg (1 tab PO BID X 7 days - 14 tabs/dose)


 (max 15)


(max 5)

Gonorrhea
Azithromycin & Ceftriaxone & Lidocaine & Sterile water (for lidocaine allergy) 1 g (4 tabs)
250 mg vial

(max 5)
Syphilis
Medication will only be released with a positive lab result

Benzathine Penicillin G.
2.4 million U IM

*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


Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.

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