By completing this form, I acknowledge that:
I have the authority to include this facility in the Directory.
Our facility regularly stocks and provides emergency contraception to eligible clients who request it and/or prescribes emergency contraception.
We have procedures in place to prevent clients from being denied access to emergency contraception in our facility due to personal objections of our staff.
We will notify our staff (especially those who answer the phone) that we carry and/or prescribe emergency contraception (Plan B One-Step or Next Choice) and will be listed in the Directory.
Name of facility:
Suite or Building:
Telephone Number unique to this address (each listing must have a different number)
Telephone number for public display (if different from above) (not required; first number will be used if nothing is entered)
Toll Free Number:
We are a:
If your practice EXCLUSIVELY sees only certain types of patients, please
indicate by checking the appropriate items below:
College/University Health Service Indian Health Service Military Health Service Health Maintenance Organization Established Clients Other (please specify)
Would you like to be listed in the Bedsider EC locator (?)
Do you accept Medicaid Patients?
PHARMACIES ONLY: Do you serve women under 17 without prescription under collaborative agreement (or other similar mechanism)?
No (clinics and health centers should choose "no")
CLINICS and HEALTH CENTERS: Do you stock Plan B One-Step or Next Choice at your facility?
Yes, we stock Plan B One-Step or Next Choice.
No, but we can provide a prescription for Plan B One-Step or Next Choice
Do you offer EC on-line?
Yes (if so please provide URL): No
Administrative Contact Information To complete your listing, we require contact information for an administrator at your facility.
We will contact this person annually to electronically verify your listing.
We will also contact this person if we receive any user comments about your services.
. This information will not be part of your Directory listing
Because annual renewal listings will be done electronically, we must be able to reach you by email. Please provide an
alternate email that is not likely to change in the event of staffing changes .
Name of person completing form:
Email of person completing form:
Please type the numbers shown above into the text box below: