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Free Planned Parenthood Proof Form

The Planned Parenthood Proof form is a document used by patients to request medical services, particularly related to pregnancy testing and reproductive health. This form collects essential information such as personal details, medical history, and consent for treatment, ensuring that patients understand their rights and the services provided. For those seeking assistance, completing this form is a vital step; you can start by clicking the button below.

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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 _______________

Common mistakes

When filling out the Planned Parenthood Proof form, many people make common mistakes that can delay their services. One frequent error is not printing information clearly. The form explicitly states to "PLEASE PRINT LEGIBLY." If the handwriting is unclear, it may lead to miscommunication and require the form to be filled out again.

Another mistake is skipping required fields. Important sections, such as the last name, first name, and date of birth, must be completed. Omitting any of these details can cause delays in processing and may prevent the clinic from providing timely care.

Many individuals also forget to check the appropriate boxes regarding their preferred contact methods. This is crucial for receiving test results and other important information. If these boxes are left unchecked, the clinic may not know how to reach the patient effectively.

Some people mistakenly provide an email address for test results. The form clearly states that email cannot be used for this purpose. Providing an email may create confusion, leading to delays in receiving important health information.

Another common error is not providing a password for receiving test results over the phone. This password is necessary to ensure confidentiality. Without it, the clinic may not be able to share sensitive information with the patient.

Failing to explain any abnormal menstrual cycle is also a frequent oversight. If the last menstrual period was not normal, it is essential to provide details. This information helps the healthcare provider understand the patient’s situation better.

Some individuals neglect to answer questions about their medical history, such as experiences with abnormal bleeding or ectopic pregnancy. These details are vital for the clinic to assess the patient's health accurately and provide appropriate care.

Lastly, people often overlook the section asking how they heard about Planned Parenthood. This information can be helpful for the clinic’s outreach efforts. Providing an answer helps the clinic understand which methods are effective in reaching the community.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is important to ensure accuracy and clarity. Here are some essential do's and don'ts to keep in mind:

Do print your information clearly. This helps avoid misunderstandings and ensures that your details are recorded accurately.
Do provide all requested information, including your contact details and medical history. Complete information is crucial for your care.
Do read the instructions carefully before signing. Understanding what you are consenting to is vital for your rights and privacy.
Do ask questions if you are unsure about any part of the form. Staff are available to assist you and clarify any concerns.

Don't leave any sections blank unless instructed. Incomplete forms may delay your services or care.
Don't provide inaccurate information. Honesty is key, as it affects your treatment and the advice you receive.
Don't forget to check your contact preferences. Ensure you select how you wish to be contacted regarding test results.
Don't hesitate to express your needs for language assistance or other accommodations. Your comfort and understanding are important.

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Similar forms

The Planned Parenthood Proof form shares similarities with several other documents used in healthcare settings. Each of these documents serves to collect important patient information and ensure informed consent. Below are five documents that are comparable to the Planned Parenthood Proof form:

Informed Consent Form: This document outlines the risks and benefits of a procedure or treatment. Like the Planned Parenthood Proof form, it ensures that patients understand what they are consenting to before receiving care.
Patient Registration Form: This form collects essential demographic and insurance information from patients. Similar to the Planned Parenthood Proof form, it gathers data necessary for the healthcare provider to deliver services effectively.
HIPAA Acknowledgment Form: This document informs patients about their rights regarding health information privacy. Like the Planned Parenthood Proof form, it emphasizes the importance of confidentiality and the patient's understanding of privacy practices.
Medical History Questionnaire: This form collects detailed information about a patient's past medical conditions and treatments. It serves a similar purpose to the Planned Parenthood Proof form by helping healthcare providers assess the patient's needs and risks.
Hold Harmless Agreement: This legal document is essential for mitigating risks in various business transactions. To learn more about the specific requirements in Michigan, visit TopTemplates.info.
Release of Information Form: This document allows healthcare providers to share patient information with other entities, such as specialists or insurance companies. Like the Planned Parenthood Proof form, it requires patient consent and ensures that individuals understand how their information will be used.

Free Planned Parenthood Proof Form

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