SUBSCRIPTION FORM

This page is to be used by provider clinics to subscribe to the

Abortion Help World Directory.

 

You need to provide some basic information necessary to construct a draft link or homepage. We will upload it to our server within 48 hours and send you a confirmation e-mail. Once this draft is visible on the Internet, you can inspect it, add content and make the necessary changes to suit your requirements.

 

Text information in any language can be easily incorporated into the listing.

  

Subscription
   
#  marks required information
DETAILS  

enter your details
SERVICE:  

 

FIRST NAME: #

 

SURNAME: #

 

POSITION:  

 

CLINIC NAME:  

 

CATEGORY:  

 

CLINIC WEBSITE:  

 

AH CLINIC ID:  

  if issued
ADDRESS  

enter clinic address (if more then one, specify in Notes)
SUITE/ROOMS:  

 

NO. AND STREET:  

 

SUBURB/CITY:  

 

STATE/PROVINCE:  

 

POST/ZIP CODE:  

 

COUNTRY:  

 

CONTACTS  

enter contacts for clinic
CLINIC EMAIL: #

 

ADMIN TEL::  

 

APPOINT TEL:  

 

TOLL FREE:  

 

FAX:  

 

ENQUIRY  

write your enquiry in the box below
NOTES:  

 

LINK PAGE  

 information to appear in the link page in the Directory
CONTENT:  

 

   

 additional information can be emailed directly to

webmaster@abortion-help.com