Add Listing: Provider Consent and Information Form

Instructions

This form is for sexual and reproductive health service providers to add a listing or update an existing listing in Action Canada’s provider directory. 

The directory has two views:

  • A public view available on the Action Canada website to help visitors find sexual health services based on their location
  • A login-secure private view with additional listings 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 request a listing that appears in both views, or only the private one if preferred.

  • Selecting "Public" for the fields with this option and "Public Listing" for the overall type will display these fields on the public directory when available.
  • Selecting "Private" for the fields with this option will hide this information from the public directory on a Public listing.
  • Additionally, selecting a "Private Listing" will hide the name of the clinic and add instructions to contact the Access Line for more information. E.g.:
    • [City] unlisted clinic
      Contact info provided through the Access Line
      City, Province
      ​​​​​​​1-888-642-2725

Please provide all information as you would like it to appear. Contact mel@actioncanadashr.org with any questions or concerns.

Clinic Information

Type of Listing

Selecting “Private Listing," will limit the information available to the public on Action Canada’s Website. See Instructions above for more information.
Categories to be listed under on ActionCanadaSHR.org
Location
Contact
Where patients can call to make an appointment.

Additional details

Can patients self-refer?
Languages care is provided in:
Coverage
Please provide any additional information about your services that we should know when directing patients. These notes are always only visible to our team.
STBBIs and HIV
Contraception
Pregnancy
Abortion
Counselling, Classes, & Support
Exams
Gender Affirming Care

Agreement

I understand that the information provided above will be saved in Action Canada for Sexual Health and Rights' password-protected provider directory, available for authorized staff and volunteers to consult when supporting people who contact the Access Line seeking services.

I understand that unless I indicate “Private Listing” on this form, the clinic 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