Registration

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 www.1800myoptions.org.au or contact carolynm@1800myoptions.org.au

Note: Questions marked with an asterisk ( * ) require an answer.
Registration
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.

Privacy
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 carolynm@1800myoptions.org.au



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. 

Question Title

* 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. 

Name and role of person completing this form

Question Title

* 2. Name and role of person completing this form

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

Question Title

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

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

Question Title

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

Contact details

Question Title

* 5. Contact details

Service opening hours

Question Title

* 6. Service opening hours

Sexual and reproductive health services available
(Please select ALL that apply)

Implanon is a registered trademark of Merck Sharp & Dohme (Australia) Pty Ltd.
Mirena is a registered trademark of Bayer Group Germany

Question Title

* 7. Sexual and reproductive health services available
(Please select ALL that apply)

Implanon is a registered trademark of Merck Sharp & Dohme (Australia) Pty Ltd.
Mirena is a registered trademark of Bayer Group Germany

If you provide pregnancy termination services, what is the minimum and maximum gestation for these services?

Question Title

* 8. If you provide pregnancy termination services, what is the minimum and maximum gestation for these services?

Is a GP referral required for your services?

Question Title

* 9. Is a GP referral required for your services?

What else should WHV know about your service?
(Please select ALL that apply)

Question Title

* 10. What else should WHV know about your service?
(Please select ALL that apply)

How would you like your service information to be made available via 1800 My Options?
(Please select ONE option only)

Question Title

* 11. How would you like your service information to be made available via 1800 My Options?
(Please select ONE option only)

Please provide any further information you think may be relevant

Question Title

* 12. Please provide any further information you think may be relevant

This completes your registration. Thank you for your input.

WHV will contact you, as necessary, to clarify any information provided.

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