Clinic Consent and Information Form

Introduction

Thank you for adding or updating 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.

After submitting this form, you will be directed to a short "Accessibility Checklist”. Please fill out all criteria that applies to your clinic and feel free to reach out to our Access Line Manager, Jessa Millar at [email protected] if you have any questions or would like to discuss anything in relation to this process.

Are you updating information for a clinic that we already have listed in our public &/or private SRH service provider directories, or is this a new submission?

New Submission

Update Current Listing

I’m not sure

Clinic Information

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

Clinic Name

Street Address

City

Province

Postal Code

Phone Number

Please indicate a phone number where clients can call to make an appointment.

Phone Extension

Please indicate an email address that clients seeking more information can use to contact your clinic.

Clinic Website

Hours of Operation

Public Transit Directions

Care is provided in:

English

French

Other…

Self-referral

Yes

Coverage

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

What types of health care coverage do you accept?

Any fees for those with provincial health care coverage?

Any financial support for those without provincial coverage?

Services Offered

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

STBBIs & HIV

Vaccination (Hep. A&B, HPV)

STBBI Testing

STBBI Treatment

HIV testing

HIV Point of Care Testing

HIV Prevention (PrEP)

HIV Treatment and Support

Contraception

Subsidized/Low-Cost Contraception

IUD Insertion

Contraceptive coverage

Emergency Contraception

Free Condoms

Pregnancy

Pregnancy Testing

Pre-Natal Care and Referral to Appropriate Services

Labour and Delivery

Post-Natal Care

Abortion

Medical Abortion

Surgical Abortion

Post-Abortion Services

For medical abortion, what is the G.A. cut off of your ?

For surgical abortion, what is the G.A. limit of your?

What type of anesthesia / medications are used?

Do you provide virtual abortion services?

Yes

Counselling, Classes & Support

Counselling, Classes and Supports

Parenting Classes and Supports

Pregnancy Options Counseling

Safer Sex Information and Counseling

Peer-Based Education Programs

Peer-Support Groups

Exams

Physical Exams

Pelvic Exams

Cervical Screening (Pap Tests)

Ultrasound/Lab Work

Blood Work

Hormone Therapy

Gender-Affirming and Transition-Related Surgeries

Interpretation/Translation Services

Harm Reduction Services

Non-Insured Patient Care

Other

Tell us what your other services are

Agreement

I understand that for increasing access to sexual and reproductive health, the information provided above will be made public on Action Canada for Sexual Health and Rights' online sexual health hub to increase the public’s access to sexual and reproductive health services.

I understand that the above-mentioned clinic, hospital, or centre, as well as contact information, will appear on the public online directory, or only in the private directory if selected.

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.

First Name

Last Name

Job Title

Phone Number

Phone Extension

Additional Comments or Conditions

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

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

Submitting this form will act as my signature.