About the 1800 My Options database
1800 My Options
, an independent service funded by the Victorian State Government and provided by Women's Health Victoria, provides non-preferential and non-biased information and referrals to women seeking pregnancy options, contraceptive and sexual health services.

This form is designed for sexual and reproductive health care providers to register their service details with 1800 My Options. Service providers can choose to be listed publicly, or to have their information stored privately. When you complete and submit this form to us, we will collect your personal information (including name, address, phone 
number, other contact details, hours of operation and services provided). We collect this information to enable us to refer women in your area to you, as appropriate. 

For more information about 1800 My Options, please visit or contact
When you register for the 1800 My Options database you can choose to be on our public or private database:
  • Public: your information is accessible to the public via the 1800 My Options website; 
  • Private: your information is only accessible to the 1800 My Options team, in order to provide information directly to women seeking services or health professionals over the phone.
When you register your services with us, your location will be geo-mapped. That is, your street address and relevant contact details, together with a summary of the services you provide (as notified by you to us) will be listed in an online and interactive map. This enables us to search for specific services in a particular area. 

If you consent to your information being public via the 1800 My Options website, your information will be made available to third parties through this map on the 1800 My Options website. If you consent to the private database, your information will be stored on a separate server and will not be made available through the 1800 My Options website, and will be on a map only available to 1800 My Options staff in order to make appropriate referrals by phone. 

We rely on you to provide us with accurate and up-to-date information to ensure that our database and referral service is effective. Should your details change, or should you want to change your the public or private status of your information, please contact us and we will update our database accordingly. If you wish to no longer be part of the database, please contact us and we will remove you from the database as soon as practicable.

We collect, hold, use and disclose personal information in accordance with our privacy policy. Please note that the storage of information within the 1800 My Options database will comply with national privacy legislative requirements as well as with Victorian State Government legislative requirements. 

For more information please contact 1800 My Options on 9653 0204 or

* 1. Please confirm that you are authorised to submit this form. 

Authorisation and Consent
Where you complete and submit this form to us, and consent to the inclusion of your information in our database, you are deemed to have read and understood the information above and to agree to our disclosure of your information to third parties, including women seeking services or health professionals via our referral service and via the 1800 My Options database. By completing and submitting this form to WHV, you are deemed to be authorised by or on behalf of the health service provider or practitioner to submit this information to WHV. 

* 2. Name and role of person completing this form

* 3. On whose behalf are you submitting this form?
(eg: practice and/or health care professional/s)

* 4. Service provider consent
(Please select the ONE option that applies):