The Planned Parenthood Proof form is a crucial document that patients complete to receive medical services, particularly related to pregnancy testing and reproductive health. This form collects essential personal information, medical history, and preferences for communication, ensuring that each patient receives tailored care while maintaining their privacy. If you’re ready to take the next step, please fill out the form by clicking the button below.
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Understanding the Planned Parenthood Proof form is essential for ensuring a smooth process during your visit. Here are some key takeaways to keep in mind:
By keeping these points in mind, you can navigate the Planned Parenthood Proof form with confidence and clarity.
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
TV
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
No
Are you currently experiencing?
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?
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
For NEGATIVE Results-
V=Verbal H=Handout
CIIC EC
CIIC Pregnancy Tests
Explained limitations of test (morning urine
CIIC HOPE
STIs
sample/time since last period)
Advised re-test in 1-2 weeks
BCM Options
CIIC Contraceptive Implant
Prenatal Care
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:
Revised March 2014
Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices I-B-2a Revised June 2012
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 _____________________________________________________
The Planned Parenthood Proof form shares similarities with the Patient Registration Form commonly used in healthcare settings. Both documents collect essential patient information such as name, address, and contact details. They often require individuals to disclose their medical history and current health status. This information helps healthcare providers understand the patient's background and needs, ensuring appropriate care and treatment. Additionally, both forms emphasize the importance of confidentiality and may include sections for emergency contact information.
Another document akin to the Planned Parenthood Proof form is the Informed Consent Form. This form outlines the procedures and treatments a patient may undergo, ensuring they are fully aware of the associated risks and benefits. Like the Proof form, it requires the patient's signature, indicating their understanding and agreement to proceed. Both documents aim to protect the rights of patients while promoting informed decision-making in their healthcare journey.
The Medical History Questionnaire is also similar to the Planned Parenthood Proof form. This document gathers comprehensive information about a patient's past medical conditions, surgeries, and family health history. Both forms serve to inform healthcare providers about potential risks and necessary precautions. They play a crucial role in tailoring care to meet the specific needs of each patient, enhancing the overall quality of healthcare services.
The Authorization for Release of Medical Records form bears resemblance to the Planned Parenthood Proof form in its focus on patient consent and confidentiality. This document allows patients to authorize the sharing of their medical information with other healthcare providers or institutions. Similar to the Proof form, it highlights the importance of patient privacy and ensures that individuals have control over their health information.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Notice is another document related to the Planned Parenthood Proof form. This notice informs patients about their rights regarding their health information and how it may be used or disclosed. Both documents emphasize the commitment to maintaining patient confidentiality and outline the procedures for addressing any concerns related to privacy practices.
To effectively address potential legal issues, individuals and entities may require guidance on preparing a Cease and Desist Letter template for their specific needs. This template serves as a critical tool in legally articulating demands for cessation of objectionable actions. Additional resources, such as the comprehensive guide on the Cease and Desist Letter, provide further insights into this essential process.
The Consent for Treatment form is comparable to the Planned Parenthood Proof form in that it requires patients to acknowledge their understanding of the treatment they will receive. This document ensures that patients are aware of their rights and responsibilities during their healthcare experience. Like the Proof form, it reinforces the importance of informed consent and patient autonomy in medical decision-making.
Finally, the Appointment Confirmation form shares similarities with the Planned Parenthood Proof form. This document typically includes details about the patient's upcoming appointment, such as date, time, and location. Both forms serve to facilitate communication between the patient and the healthcare provider, ensuring that patients are informed and prepared for their visits. They also help maintain an organized scheduling system within healthcare facilities.
Completing the Planned Parenthood Proof form is an important step in accessing the medical services you need. This form collects essential information to ensure your visit is efficient and your privacy is protected. Follow the steps below to fill out the form accurately.
Once you have completed the form, it will be submitted to the clinic staff. They will review your information and guide you through the next steps in your care. Make sure to keep a copy for your records if needed.
When seeking medical services from Planned Parenthood, several other forms and documents may accompany the Planned Parenthood Proof form. Each of these documents plays a crucial role in ensuring that patients receive the necessary care while understanding their rights and responsibilities.
Understanding these documents can enhance the experience of receiving care at Planned Parenthood. Each form serves a specific purpose, ensuring that patients are informed, protected, and supported throughout their healthcare journey.
Illegible handwriting: When filling out the Planned Parenthood Proof form, it is essential to print legibly. Illegible handwriting can lead to misunderstandings or errors in processing your information.
Incomplete information: Failing to provide all requested details, such as last name, first name, or contact information, can delay your appointment or test results. Ensure that every section is filled out completely.
Incorrect contact method selection: It is important to select the correct methods for receiving test results. Choosing inappropriate options may hinder communication, especially if results are abnormal.
Neglecting to provide a password: If you wish to receive test results over the phone, you must provide a password. Omitting this information can prevent you from accessing your results efficiently.
Not disclosing medical history: It is crucial to share relevant medical history, including any previous pregnancies or complications. This information helps healthcare providers give you the best care possible.
When filling out the Planned Parenthood Proof form, it is essential to approach the task with care and attention to detail. Here is a list of things to do and avoid: