Clinic Consent and Information Form: Add Listing

Introduction

Thank you for adding your clinic’s information to Action Canada’s public and/or private directory of Sexual and Reproductive Health Service Providers.

The public directory is available 24/7 to help visitors to our website find out where they can access a variety of sexual health services, while our login-secure private directory is only accessible to our Access Line staff and volunteers who use it to support people reaching out over our Access Line from 9am-9pm EST, 7 days a week.

Please fill out all criteria that applies to your clinic and feel free to reach out to our Access Line Manager, Jessa Millar at jessa@actioncanadashr.org if you have any questions or would like to discuss anything in relation to this process.

Clinic Information

Please fill out the following information as you would like it to appear on the directory.

Please indicate a phone number where clients can call to make an appointment.
Care is provided in:
Self-referral

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
STBBIs and HIV
Contraception
Pregnancy
Abortion
(integer only, e.g. 9)
(integer only, e.g. 9)
Counselling, Classes, & Support
Exams
Gender Affirming Care

Agreement

I understand that for increasing access to sexual and reproductive health, 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 Only” in the final section of this form, the information about the above-mentioned clinic, hospital, or centre, as well as contact information, will also appear in Action Canada for Sexual Health and Rights' online public sexual and reproductive health provider 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 regarding the services offered at said clinic, hospital, or centre. I further agree to hold harmless Action Canada for Sexual Health and Rights from and against any and all damages and claims.

Consent to Share with SHORE Centre’s Choice Connect App

Action Canada for Sexual Health and Rights works together with our affiliate SHORE Centre to maintain up-to-date provider information to provide to people who connect with our Access Line, Sexual Health Hub and SHORE Centre’s Choice Connect app for information about their nearest abortion provider. Action Canada shares this information with SHORE Centre’s Choice Connect app to empower people across Canada to be able to find an abortion provider in their community.

By selecting the “Private Listing Only” option below, you are limiting what information is shared with SHORE Centre and what information is available to the general public on Action Canada’s Public Directory and SHORE Centre’s Choice Connect app. 

Below is an overview of what information is and is not shared with SHORE Centre and in public listings when a Private Listing is selected. 

Shared / Public Information Not Shared / Not Public Information 
✔️ Clinic City
✔️ Clinic Province 
✔️ Clinic Postal Code  
✔️ Action Canada’s Access Line Number 
❌ Name of Clinic 
❌ Street Address
❌ Clinic Contact Information 
❌ Clinic Website


 

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

Private listing only
This information will be kept in our database for use by Access line staff to refer clients, but the public directory will show: 

[City] unlisted clinic

Address will be provided through the Access Line
City Prov A1A 9Z9

1-888-642-2725
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