Clinic Listing Suggestion

Your Name*

First Name

Last Name

Your Email*

Your Phone Number*

Your relationship to the clinic*

Name of Clinic*

Clinic Website Link*

Links for you Social Media Pages*

One link per line, please

Clinic Executive Director*

Clinic Nurse Manager*

Number of Locations*

Address for Location 1*

Address Line 1

Address Line 2

City

State

ZIP Code

Additional Locations*

More than 1 location? Please list additional locations here, 1 per line

Who is your medical director and what is their speciality?*

Which days per week are you open?*

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

How many hours per week is your nurse manager on site?*

How many hours per week are ultrasounds provided?*

How many hours per week are medical services provided?*

How many full-time paid staff do you have? *

How many volunteers do you have?*

Do you have the capacity to see an increase in the following – check all that apply

Ultrasound*

Yes No NA

STD/STI Testing*

Yes No NA

Pregnancy Test*

Yes No NA

Consultations*

Yes No NA

Other areas (please describe)*

Do you provide material assistance? If yes, how many hours are spent on material assistance and parenting education?*

How many pregnancy tests do you perform on an average month?*

Are you satisfied with the number of clients you see?*

Please explain

Are you satisfied with the type of clients you see?*

Please explain

How would you describe your average client?*

Do you provide consultation services for men?*

Do you offer or refer for abortions?*

Do you offer or refer for abortion pill reversal?*

What are you currently doing to market your clinic in your community? Check all that apply*

Social Media Digital Marketing Google AdWords Radio Television Billboards Community Events Active Chamber of Commerce Member

Other:

If you checked "digital marketing" above, which types of digital marketing do you currently use?*

Why would you like to be listed on the My Choice Network directory?*

What else should we know about your clinic?*

Please upload a minimum of 3 images of your location including exterior of the building, waiting room and 1 patient room. ( If you do not have those available at this time, you can send separately to clinic@mychoicenetwork.org)

Image 1

No File Chosen

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Image 2

No File Chosen

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Image 3

No File Chosen

File uploads may not work on some mobile devices.