Clinic Consent and Information Form: Add Listing

Thank you for your interest in being added to Action Canada’s directory of sexual and reproductive health service providers!

Our directory has two views:

  • A public version that is available 24/7 on our website to help visitors find a variety of sexual health services based on their location, and
  • A login-secure private version with additional listings that are only accessible to our staff and volunteers to support people who contact the Access Line 7 days a week from 9AM-9PM EST.

Providers can ask to be listed in both versions of the directory, or only the private one if preferred.

Instructions

Please provide all applicable information as you would like it to appear in the directory.

Selecting "Public" for the fields with this option (i.e address, phone number, email address, website) and "Public Listing" will display each of these fields on the public directory when available. Selecting "Private" for the fields with this option will hide this information from the public directory.

Additionally, selecting a "Private Listing" will hide the name of the clinic and add instructions to contact the Access Line for more information (see example below).

Please contact melissa@actioncanadashr.org with any questions or concerns.

Clinic Information

Categories to be listed under on ActionCanadaSHR.org
Clinic Location
Where patients can call to make an appointment.
Phone Preferences
Email Preferences
Website Type
Care is provided in:
Can clients self-refer?

Coverage

Questions about coverage are mandatory. Please answer "no" or "n/a" to coverage questions if they do not apply.

Services Offered

Additional options will appear for some categories of services. Select all that apply.

Services
Type of Listing
By selecting “Private Listing," the information available to the general public on Action Canada’s Public Directory will be limited. The name of the clinic/provider will be hidden with directions to contact the Access Line for more information in the following format:

  • [City] unlisted clinic
    Contact info provided through the Access Line
    City, Province
    ​​​​​​​1-888-642-2725

Consent to Share information with SHORE Centre’s Choice Connect App

Action Canada for Sexual Health and Rights works with our affiliate SHORE Centre to maintain up-to-date and consistent abortion provider information through our Access Line and their Choice Connect app.

If you selected a "Public Listing,” you also have the option to publicly list this information in the Choice Connect app.

Click here to see the difference between a public listing and a private listing on the SHORE Centre’s Choice Connect app. 

Agreement

I understand that the information provided above will be saved in Action Canada for Sexual Health and Rights' online private, password-protected, sexual and reproductive health provider directory, available for authorized staff and volunteers to consult when supporting callers to the Access Line in finding services.

I understand that unless I indicate “Private Listing” in the final section of this form, the name and contact information provided will also appear in Action Canada for Sexual Health and Rights' public directory, available to the public through our website.

I understand that individual people's names and their addresses will not be made public on the directory.

I agree with the terms and conditions in this agreement, and hereby grant Action Canada for Sexual Health and Rights the right and permission to publish the information disclosed in this form. I further agree to hold harmless Action Canada for Sexual Health and Rights from and against any and all damages and claims.

Sign above