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Planned Parenthood Proof PDF Form

The Planned Parenthood Proof form is a document used by individuals seeking medical services related to pregnancy testing and reproductive health. This form collects essential information from patients, including personal details and medical history, while ensuring confidentiality and compliance with health regulations. It serves as a vital tool in facilitating patient care and communication between healthcare providers and patients.

Customize Planned Parenthood Proof

Table of Contents

When seeking medical services at Planned Parenthood, one important document you will encounter is the Planned Parenthood Proof form. This form serves multiple purposes, primarily ensuring that patients receive the necessary medical care while also protecting their rights and privacy. At its core, the form collects essential personal information, such as your name, contact details, and medical history. It also includes sections for understanding your health care preferences, such as how you wish to be contacted with test results, and whether you have a living will. Additionally, the form addresses your current health status, including any symptoms you may be experiencing and your contraceptive methods. Importantly, it emphasizes patient education, ensuring that you are informed about the tests and treatments available to you. The form also requires your acknowledgment of privacy practices, highlighting the commitment of Planned Parenthood to maintain confidentiality throughout your care. This comprehensive approach not only facilitates a smooth medical experience but also empowers you to make informed decisions about your health.

Common mistakes

Illegible handwriting: Many individuals rush through the form, resulting in unclear or messy handwriting. This can lead to misunderstandings or miscommunication regarding personal information, which may delay services.
Incomplete information: Leaving sections blank or failing to provide necessary details can cause significant delays. Every part of the form is important for ensuring accurate medical care and proper communication.
Incorrect contact preferences: Some people forget to check their preferred methods of contact. This can lead to missed important updates or results, especially if the clinic needs to reach out regarding test outcomes.
Not disclosing medical history: Omitting relevant medical history, such as previous pregnancies or current medications, can impact the care provided. It is essential to be open and thorough to ensure the best possible medical advice and treatment.

Example - Planned Parenthood Proof Form

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 _______________

More About Planned Parenthood Proof

What is the Planned Parenthood Proof form and why is it necessary?

The Planned Parenthood Proof form is a document that collects essential information from patients seeking medical services, particularly related to pregnancy testing and reproductive health. It serves multiple purposes, including ensuring that patients are informed of their rights and responsibilities, maintaining confidentiality, and gathering necessary medical history and personal details. Completing this form accurately is crucial for providing appropriate care and for the clinic to understand the specific needs and circumstances of each patient.

How does Planned Parenthood ensure patient confidentiality when using the Proof form?

Planned Parenthood is committed to maintaining the confidentiality of all patients. The Proof form includes sections that allow patients to specify how they prefer to be contacted regarding test results or other sensitive information. Options include phone calls or mail, with the assurance that communications will be conducted discreetly, often in plain envelopes. Additionally, the clinic adheres to strict privacy practices as outlined in their Notice of Health Information Privacy Practices, ensuring that personal information is protected in accordance with legal standards.

What should I do if I have questions about the information requested on the Proof form?

If you have questions or concerns about any part of the Proof form, it is advisable to discuss them with the clinic staff before signing. The staff is trained to provide clarity on the information requested and can explain the significance of each section. It is important that you fully understand the form, as the information you provide will impact your healthcare choices and the services you receive.

What happens if I change my mind about receiving services after completing the Proof form?

Patients have the right to change their minds about receiving medical services at any point. If you decide not to proceed with the services after completing the Proof form, you can inform the clinic staff of your decision. They will respect your choice and ensure that you understand your options moving forward. It is important to communicate any changes in your decision to avoid any misunderstandings regarding your care.

Key takeaways

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

Legibility Matters: Ensure that all information is printed clearly. This helps prevent misunderstandings and delays in your care.
Confidentiality is Key: The form emphasizes the importance of maintaining your privacy. Be sure to select your preferred methods of communication for receiving test results.
Accurate Information: Provide truthful and complete details about your medical history and current situation. This information is crucial for your healthcare provider to offer appropriate care.
Understanding Your Rights: You will receive a copy of the Patient’s Bill of Rights and Responsibilities. Familiarize yourself with this document to understand your rights as a patient.
Emergency Protocols: The form includes instructions on what to do in case of an emergency. Make sure you know how to access care quickly if needed.
Ask Questions: If anything on the form or related to your care is unclear, don’t hesitate to ask for clarification. Your understanding is vital for effective treatment.

Form Attributes

Fact Name	Description
Provider Information	The form is from Planned Parenthood of Southeastern Virginia, located at 403 Yale Drive, Hampton, VA, and 515 Newtown Road, Virginia Beach, VA.
Contact Numbers	Patients can reach the Hampton office at (757) 826-2079 and the Virginia Beach office at (757) 499-7526.
Patient’s Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities along with the Patient Complaints policy.
Confidentiality Assurance	Planned Parenthood commits to maintaining patient confidentiality, using various contact methods only with patient consent.
Medical Screening	The form includes a medical screening section where patients answer questions about their health and pregnancy status.
Legal Obligations	If tests for sexually transmitted infections return positive, reporting to public health agencies is required by law.
Patient Consent	Patients must sign to acknowledge understanding of the health information privacy practices and to consent to medical services.

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Dos and Don'ts

When filling out the Planned Parenthood Proof form, consider the following guidelines to ensure a smooth process.

Do print legibly. Clear handwriting helps avoid misunderstandings.
Do provide accurate information. Ensure all details, especially contact information, are correct.
Do check your preferred contact method. Indicate how you wish to be contacted for results.
Do ask questions. If anything is unclear, seek clarification from staff.
Do respect confidentiality. Understand that your information will be kept private.

Don't rush through the form. Take your time to fill it out completely.
Don't skip questions. Answer all sections to the best of your ability.
Don't use abbreviations. Write out all terms to avoid confusion.
Don't hesitate to disclose important health information. This is crucial for your care.
Don't forget to sign and date the form. An unsigned form may delay your service.