The Planned Parenthood Proof form is a document used by patients seeking medical services related to pregnancy testing and reproductive health. It collects essential information such as personal details, medical history, and preferences for communication. This form helps ensure that patients receive appropriate care while maintaining their confidentiality and rights.
The Planned Parenthood Proof form is a document used to collect essential information from patients seeking medical services, particularly for pregnancy testing. It ensures that the clinic can provide the necessary care while maintaining patient confidentiality.
When filling out the form, please print legibly. Provide your personal information, including your name, address, and contact details. Indicate your reason for the test and any relevant medical history. Make sure to check the preferred methods of contact for receiving test results.
You will need to provide your name, contact information, date of birth, income, family size, and medical history. Additionally, you will be asked about your current health status, including any symptoms you may be experiencing.
Planned Parenthood is committed to maintaining your confidentiality. Your information is kept private, and results are communicated through secure methods, such as phone calls or mail in plain envelopes, unless you specify otherwise.
If you have any questions or need assistance while completing the form, feel free to ask the staff at Planned Parenthood. They are there to help clarify any information and ensure you understand the process.
Yes, you can receive your test results over the phone. However, you must provide a password on the form to ensure that only you can access your information.
If further diagnosis or treatment is necessary, you will receive referrals. It is your responsibility to follow up on these referrals and any associated costs.
Yes, if you require language interpretation services, please inform the staff. They will assist you in accessing these services, although immediate availability may vary.
You have the right to change your mind about receiving services at any time. Your comfort and consent are paramount, and you can withdraw your consent if you choose.
Misconceptions about the Planned Parenthood Proof form can lead to confusion. Here are eight common misunderstandings:
Illegible handwriting: Many people rush through the form, leading to unclear writing. This can cause confusion and delays in processing.
Missing information: Failing to fill in required fields, such as contact information or medical history, can result in incomplete applications.
Incorrect contact methods: Not checking the preferred contact methods can lead to missed communications about test results.
Overlooking the password section: Forgetting to provide a password for receiving test results over the phone can complicate access to important information.
Inaccurate income reporting: Misstating monthly income or family size can affect eligibility for services.
Neglecting to explain medical history: Failing to provide details about previous pregnancies or medical conditions can hinder proper care.
Not asking questions: Some individuals do not seek clarification on unclear sections, which can lead to misunderstandings about the services provided.
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 _____________________________________________________
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