Clinic 35 Health Promotion Request Form

Clinic 35 is a Sexual & Reproductive Health clinic that offers a confidential and safe setting to discuss sexual health concerns and receive comprehensive sexual and reproductive health care. Our clinic prioritises under-screened groups but is open to everyone.

Our Clinic 35 nurses can provide health promotion about our services locally e.g. secondary schools, community meetings, and forums.

Requester Details

First Name *

Last Name *

Contact Number *

Email Address

Organisation Name *

Which option best describes your Organisation? *

Please Specify

Organisation Address *

Street address *

City *

State *

Postcode *

Is this the same address as the Event? *

YesNo

Event Request Details

Request Date

Event Name *

Event Date

Start Time *

Finish Time *

Set up time *

Pack up time *

Location of Event *

Street address *

City *

State *

Postcode *

How many attendees are expected to attend? *

What is the Age Group Range expected? *

Is the Event/Activity Indoors or Outdoors? *

YesNo

Is power, internet and audio visual equipment supplied?

YesNo

What would you like from Clinic 35’s attendance? *

Please specify which areas of Sexual & Reproductive Health would you like for us to focus on during this Event? *

Do you need us to bring anything in particular along?

Why did you choose to have a Clinic 35 Health Promotion session at your Event/Activity? Where did you hear about our service?

Are there any other details you would like to specify?

Save and Complete Later