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Free Planned Parenthood Proof Form in PDF

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to facilitate medical services, including urine pregnancy tests. This form collects essential information from patients, such as personal details, medical history, and preferences for communication regarding test results. Ensuring patient confidentiality and informed consent are key components of the process, allowing individuals to make educated decisions about their healthcare options.

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Document Sample

PLANNED PARENTHOOD® OF SOUTHEASTERN VIRGINIA

403 Yale Drive, Hampton, VA 23666 (757)826-2079

515 Newtown Road, Virginia Beach, VA 23462 (757)499-7526

PLEASE PRINT LEGIBLY

URINE PREGNANCY TEST

 (PLEASE CHECK) I have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy

Last Name:

First Name:

Middle Initial:

Address:

Apt #

City:

State:

Zip Code:

Employer:

Email address: (cannot be used for test results)

Home Phone #:

Cell Phone #:

Work Phone #:

Emergency Contact Name:

Phone Number:

We are committed to maintaining your confidentiality. At times it is necessary for us to contact you, usually with the

results of an abnormal test, through phone calls, email, text &/or mail (plain white envelope)

Please check the methods we can use to contact you? Phone Call

Mail

Please provide a password to receive test results over the phone____________________

Date of Birth

Sex  Female

 Transgender

Monthly Income

Family Size Supported By

Pronoun you like:  She  Other ____

Income

Do you have a living will?

 Yes

No

How did you hear about us?  AD (circle)

Billboard

Phonebook

Radio

Newspaper/Magazine

 Other Planned Parenthood

 Doctor

Family

Friends

School

Online

Facebook

Race

 Caucasian

 American Indian/Alaskan

Multiracial

Ethnicity

 African American

 Asian

 Pacific Islander

Other

Hispanic? Yes  No

Highest Level Of Education Completed  Middle School

 High School Some College

Bachelors/Masters/PhD

MEDICAL SCREENING (COMPLETED BY CLIENT)

1st day of last menstrual period __________

Was it normal?  Yes  No If no, explain:______________________

Reason for Test

 Planned Pregnancy  Contraceptive Failure  No Regular Birth Control

Test Results You Hope To See

 Negative

 Positive

 Doesn’t matter

Yes

Are you currently experiencing?

Yes

Are you currently using birth control?

Spotting/Bleeding

Fever

If yes, what method? ___________________

Abdominal Pain

For how long?

Vomiting

Do you have a history of?

Yes

Abnormal Bleeding

Would you like to discuss problems related to a

Ectopic Pregnancy

rape or emotional/physical/sexual abuse?

Missed or Spontaneous Abortion (Miscarriage)

Has your partner ever messed with your birth control or tried to

Pelvic Infection

get you pregnant when you didn’t want to be?

Are you currently experiencing any signs or

Does your partner refuse to use a condom when you ask?

symptoms of pregnancy?

Has your partner ever tried to force or pressure you to become

If yes, explain:

pregnant when you didn’t want to be?

Are you afraid of your partner?

ASSESSMENT (COMPLETED BY CLINIC STAFF)

Gravida

Para

Live Births

Spontaneous Abortion __ __ Elective Abortion_ ___ Living children _ __

Urine high-sensitivity HCG Pregnancy Test Order/Result:  Negative Positive (EDC:_______EDD:________)  Indefinite

Patient Education				V	H		V	H	For NEGATIVE Results-
V=Verbal H=Handout			CIIC EC			CIIC Pregnancy Tests			 Explained limitations of test (morning urine
	V	H	CIIC HOPE			STIs			sample/time since last period)
	V	H	CIIC HOPE			STIs			 Advised re-test in 1-2 weeks
BCM Options			CIIC Contraceptive Implant			Prenatal Care			 Advised re-test in 1-2 weeks
BCM Options			CIIC Contraceptive Implant			Prenatal Care			 Discussed blood PT
CIIC Pill,Patch, Ring			CIIC IUC			Adoption			 Discussed blood PT
CIIC Pill,Patch, Ring			CIIC IUC			Adoption			 Advised RTO if no menses for 3 consecutive
CIIC DMPA			CIIC Barriers (condoms)			Abortion			months
CIIC POPs			CIIC Essure			CI Sx of Early Pregnancy			If Minor: Encouraged parental involvement
Intake Staff Signature:						Date:
Licensed Qualified Staff Signature:						Date:

Revised March 2014

Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices I-B-2a Revised June 2012

PLANNED PARENTHOOD® OF SOUTHEASTERN VIRGINIA

403 Yale Drive, Hampton, VA 23666 (757)826-2079

515 Newtown Road, Virginia Beach, VA 23462 (757)499-7526

REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

DATE _______________________________

PATIENT LABEL

Before you give your consent, be sure you understand the information given below. If you have any questions, we will be happy to talk about them with you. You may ask for a copy of this form.

I understand that I must tell the staff if language interpreter services are necessary to my understanding of the written or spoken information given during my health care visits. I understand that free interpretive services may not be immediately available and Planned Parenthood may need to refer me to another health care facility to provide the services necessary for my care.

I understand that the information I will provide is true, accurate, and complete and that my healthcare choices will depend on that information.

I will be given information about the test(s), treatment(s), procedure(s), and contraceptive method(s) to be provided, including the benefits, risks, possible problems/complications, and alternate choices. I understand that I should ask questions about anything I do not understand. I understand that a clinician is available to answer any questions I may have.

Please note that Planned Parenthood Southeastern Virginia is a teaching institution, and that persons in training, under strict supervision, may be involved in some aspects of your care.

No guarantee has been given to me as to the results that may be obtained from any services I receive. I know that it is my choice whether or not to have services. I know that at any time, I can change my mind about receiving medical services at Planned Parenthood.

I understand that if tests for certain sexually transmitted infections are positive, reporting of positive results to public health agencies is required by law.

I will be given referrals for further diagnosis or treatment if necessary. I understand that if referral is needed, I will assume responsibility for obtaining and paying for this care. I will be told how to get care in case of an emergency.

I understand that confidentiality will be maintained as described in Planned Parenthood Southeastern Virginia Notice of Health Information Privacy Practices. I consent to the use and disclosure of my health information as described in Notice of Health Information Privacy Practices.

I hereby request that a person authorized by Planned Parenthood provide appropriate evaluation, testing, and treatment (including a birth control drug or device, if I request it).

I hereby acknowledge receipt of Planned Parenthood Southeastern Virginia notice of health information privacy practices.

Signature of patient __________________________________________________________ Date _______________

I witness the fact that the patient received the above mentioned information and said she/he read and understood same and had the opportunity to ask questions.

Signature of witness _________________________________________________________ Date _______________

CHECK HERE IF PATIENT'S GUARDIAN OR RELATIVE IS LEGALLY REQUIRED TO SIGN BELOW

Signature of any other person consenting ____________________________________

Relationship to patient ___________________________________________________

Date _______________

I witness the fact that the patient's legal guardian (or person consenting in her behalf) received the above mentioned information and said she read and understood same.

Signature of witness _____________________________________________________

Date _______________

Download Planned Parenthood Proof PDF

Key takeaways

Filling out the Planned Parenthood Proof form is an important step for individuals seeking medical services. Here are some key takeaways to keep in mind:

Print Clearly: Always fill out the form using legible handwriting to ensure that your information is accurately recorded.
Contact Preferences: Indicate how you prefer to be contacted regarding test results. Options include phone calls or mail, ensuring your privacy is maintained.
Password for Results: Create a password for receiving test results over the phone. This adds an extra layer of security to your information.
Medical History: Be prepared to provide details about your medical history, including any current symptoms or birth control methods you are using.
Confidentiality Assurance: Your confidentiality is a priority. Planned Parenthood is committed to keeping your information private, even when contacting you about test results.
Understanding Your Rights: Familiarize yourself with your rights as a patient. You have the right to ask questions and seek clarification on any part of the form or services provided.
Interpreter Services: If needed, inform the staff about any language interpreter services to ensure you fully understand the information being shared.
Emergency Care Information: You will receive instructions on how to access care in case of an emergency, so be sure to ask if you have any questions.

Completing the Planned Parenthood Proof form accurately and thoughtfully can help facilitate a smoother experience during your visit. Remember, the staff is there to assist you, so don’t hesitate to reach out with any questions or concerns.

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Instructions on How to Fill Out Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is an important step in accessing medical services. It requires careful attention to detail to ensure that all necessary information is provided accurately. Follow the steps below to complete the form correctly.

Begin by printing the form clearly. Use legible handwriting.
Check the box indicating you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy.
Fill in your last name, first name, and middle initial in the designated spaces.
Provide your address, including apartment number, city, state, and zip code.
List your employer's name and your email address (note that this cannot be used for test results).
Enter your home phone number, cell phone number, and work phone number.
Include the name and phone number of an emergency contact.
Indicate how you prefer to be contacted (phone call or mail) and provide a password for receiving test results over the phone.
Fill in your date of birth and select your sex from the options provided.
State your monthly income and family size.
Choose your preferred pronoun.
Indicate whether you have a living will.
Explain how you heard about Planned Parenthood by checking the appropriate box.
Select your race and ethnicity from the options provided.
Mark the highest level of education you have completed.
Provide the date of the first day of your last menstrual period and indicate whether it was normal.
State the reason for your test and the results you hope to see.
Answer questions regarding any current symptoms or medical history, including birth control usage.
Sign and date the form where indicated, confirming that the information provided is accurate.

After completing the form, it will be submitted to the appropriate staff for processing. Make sure to keep a copy for your records if needed. If you have any questions about the information provided or the next steps, do not hesitate to ask the clinic staff for assistance.