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Official Planned Parenthood Proof Form in PDF

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to gather essential information from patients seeking medical services, including pregnancy testing. This form ensures that patients understand their rights and responsibilities while maintaining confidentiality. It also facilitates communication regarding test results and any necessary follow-up care.

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Official Planned Parenthood Proof Form in PDF

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The Planned Parenthood Proof form serves as a vital document for individuals seeking medical services at Planned Parenthood of Southeastern Virginia. This form collects essential personal information, including the patient's name, address, and contact details, ensuring that the organization can maintain clear communication while prioritizing confidentiality. Patients are asked to indicate their preferred methods of contact for test results, which can include phone calls or mail. Additionally, the form includes sections for medical history and current health status, allowing healthcare providers to assess the patient's needs effectively. It also addresses critical aspects such as the reason for the pregnancy test, any symptoms experienced, and the patient's contraceptive methods. The form emphasizes the importance of informed consent, detailing the patient's rights and the clinic's privacy practices. By gathering this information, Planned Parenthood aims to create a supportive environment that addresses both medical and emotional needs while ensuring that each patient feels empowered to make informed choices about their healthcare.

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Steps to Using Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is a straightforward process that ensures you provide all necessary information for your visit. Once completed, this form will help facilitate your appointment and ensure that your health needs are addressed appropriately.

Print Legibly: Make sure to fill out the form using clear and legible handwriting.
Check the Box: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy by checking the box provided.
Fill in Personal Information: Enter your last name, first name, and middle initial. Provide your address, apartment number (if applicable), city, state, and zip code.
Employment Details: List your employer, email address (note that it cannot be used for test results), and your home, cell, and work phone numbers.
Emergency Contact: Provide the name and phone number of an emergency contact.
Contact Preferences: Check the methods you prefer for being contacted regarding your test results (phone call or mail). Create a password for receiving test results over the phone.
Date of Birth and Sex: Enter your date of birth and select your sex from the options provided.
Financial Information: Fill in your monthly income and family size. Include the pronoun you prefer.
Living Will: Indicate if you have a living will by checking yes or no.
Source of Referral: Select how you heard about Planned Parenthood from the list provided.
Demographic Information: Mark your race and ethnicity from the options given, and indicate if you identify as Hispanic.
Education Level: Select the highest level of education you have completed.
Medical Screening: Provide the first day of your last menstrual period and indicate if it was normal. State the reason for the test and the results you hope to see.
Current Health Status: Answer the questions regarding your current health, including any symptoms you may be experiencing and your birth control usage.
Assessment Section: Leave this section for clinic staff to complete during your visit.
Sign and Date: At the end of the form, sign and date to acknowledge that you understand the information provided.

Key takeaways

Filling out the Planned Parenthood Proof form can seem daunting, but it’s an important step in ensuring you receive the care you need. Here are some key takeaways to keep in mind:

Print Clearly: Always fill out the form legibly. This helps prevent any misunderstandings or errors in your information.
Confidentiality Matters: Your privacy is a priority. The form includes options for how you prefer to be contacted, ensuring your information remains confidential.
Provide Accurate Information: Make sure all the information you provide is true and complete. This is crucial for your healthcare decisions and outcomes.
Emergency Contact: Include an emergency contact. This person will be reached out to if necessary, so choose someone who can be easily contacted.
Understanding Your Rights: Familiarize yourself with your Patient’s Bill of Rights and Responsibilities. Knowing your rights can empower you during your visit.
Ask Questions: Don’t hesitate to ask for clarification on anything you don’t understand. The staff is there to help you navigate the process.
Review for Completeness: Before submitting the form, double-check that all sections are filled out. Incomplete forms can delay your care.

By keeping these takeaways in mind, you can feel more confident as you fill out the Planned Parenthood Proof form and prepare for your visit.

Misconceptions

Misconception 1: The Planned Parenthood Proof form is only for women.

This form is designed for individuals of all genders. It includes options for transgender individuals and allows for various pronouns to be specified.

Misconception 2: The form is only necessary for pregnancy tests.

While the form is associated with pregnancy testing, it also collects information relevant to various medical services, including contraceptive options and health screenings.

Misconception 3: Providing an email address is mandatory.

While an email address is requested, it is explicitly stated that it cannot be used for test results. Therefore, it is not a requirement for receiving services.

Misconception 4: The information provided is not confidential.

Planned Parenthood emphasizes its commitment to maintaining confidentiality. The form outlines how personal information will be protected.

Misconception 5: The form requires a lot of personal information that is unnecessary.

Many of the questions on the form are aimed at ensuring comprehensive care. Information about medical history and current health status helps providers give appropriate treatment.

Misconception 6: You cannot change your mind after signing the form.

Patients have the right to change their minds about receiving services at any time, even after signing the form.

Misconception 7: The form guarantees specific medical outcomes.

No guarantees are made regarding the results of tests or treatments. The form clearly states that outcomes cannot be assured.

Misconception 8: All services are free of charge.

While some services may be offered at low or no cost, the form indicates that patients may be responsible for obtaining and paying for referrals if further care is needed.

Misconception 9: The staff will not answer questions about the form.

The form encourages patients to ask questions if they do not understand any part of it. Staff members are available to provide clarification and support.

Preview - 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 _______________

Document Specs

Fact Name	Description
Location	The Planned Parenthood of Southeastern Virginia has two locations: Hampton (403 Yale Drive) and Virginia Beach (515 Newtown Road).
Contact Information	Patients can reach the Hampton office at (757) 826-2079 and the Virginia Beach office at (757) 499-7526 for inquiries or appointments.
Patient's Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities, ensuring they understand their rights during their visit.
Confidentiality Commitment	Planned Parenthood is dedicated to maintaining patient confidentiality, using various methods to communicate results while respecting privacy.
Legal Compliance	In Virginia, the reporting of positive results for certain sexually transmitted infections is mandated by law, ensuring public health safety.