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
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 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

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 foi@niagararegion.ca or call 905-980-6000 ext. 3779.