Sexual Health Checkup

Company

This field is for validation purposes and should be left unchanged.

Where do you live?(Required)

What Manawatū, Horowhenua, Tararua town do you live in?(Required)

If you don’t see your town please select 'Other' at the bottom of the list.

What Southland town do you live in?(Required)

If you don’t see your town please select 'Other' at the bottom of the list.

We’re unable to provide this service in your region. Please see your GP or local Sexual Wellbeing clinic.

We’re unable to provide this service in your region but we can put you in touch with providers that can. Contact us for more details or to get your treatment faster contact one of your local providers directly.

Address Details

Street Address Address Line 2 City ZIP / Postal Code

Ethnicity/Nationality

Date of birth(Required)

Gender(Required)

Full Legal Name(Required)

(as recorded on your birth certificate or passport)

Preferred Name

(if applicable)

Phone Number(Required)

Is it safe to call?(Required)

Is it safe to call?*

Yes

Is it safe to text?(Required)

Is it safe to text?*

Yes

Email Address(Required)

Enter Email Confirm Email

Is it safe to email you?(Required)

Is it safe to email you?*

Yes

Is English your first language?(Required)

Is English your first language? *

Yes

Do you need a translator?

Do you need a translator? *

Yes

You will need to arrange your own translator or English-speaking support person over 16 years of age.

Are you enrolled with a GP?(Required)

Are you enrolled with a GP?*

Yes

Name of GP(Required)

Name of Practice(Required)

Would you like a summary letter sent to your GP?

Would you like a summary letter sent to your GP? *

Yes

Do you have a Community Services Card?*(Required)

Do you have a Community Services Card?*

Yes

Card number

Expiry date

Message

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Request Appointment

Request Sexual Health Checkup

Please complete the information below and one of our admin team will contact you to schedule an appointment. We will call from a private number so that our calls remain confidential.

Alternatively, call us

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