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Fill Out a Valid Planned Parenthood Proof Template

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to collect essential information from patients seeking medical services, particularly urine pregnancy tests. This form ensures that patients understand their rights and responsibilities while maintaining their confidentiality. By providing accurate information, patients can receive appropriate care and guidance tailored to their individual needs.

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Table of Contents

The Planned Parenthood Proof form is an essential document that facilitates the provision of medical services while ensuring patient rights and confidentiality. This form collects vital personal information, including the patient's name, contact details, and emergency contact information. It also includes a section for patients to indicate their preferred method of communication regarding test results. The form addresses medical history and reasons for seeking a pregnancy test, allowing staff to understand the patient's unique circumstances better. Additionally, it encompasses important sections related to medical screening, assessment, and patient education, ensuring that individuals receive comprehensive care tailored to their needs. Patients are also informed about their rights, including the ability to ask questions and request interpreter services if necessary. By signing the form, patients acknowledge their understanding of the information provided, emphasizing the importance of clear communication in healthcare settings. The Planned Parenthood Proof form thus serves as a crucial tool in supporting individuals through their healthcare journey, fostering a compassionate and respectful environment.

Misconceptions

Misconceptions about the Planned Parenthood Proof form can lead to confusion. Here are eight common misunderstandings:

All information is shared with third parties. Many believe that their information is automatically shared. In reality, confidentiality is strictly maintained.
The form is only for women. Some think only women can use this form. However, it is inclusive of all genders, including transgender individuals.
Test results are sent via email. There is a misconception that test results will be emailed. Instead, results are communicated through phone calls or mail.
You must have insurance to receive services. Many assume that insurance is required. Planned Parenthood provides services regardless of insurance status.
The form is complicated and hard to understand. Some feel overwhelmed by the form. It is designed to be straightforward and easy to complete.
Planned Parenthood only provides abortion services. This is a common myth. Planned Parenthood offers a wide range of reproductive health services, including preventive care.
You cannot change your mind after signing. Some believe that signing the form is binding. Patients can change their minds at any time regarding services.
All services are free. While some services may be low-cost or free, others may require payment. It’s important to inquire about costs upfront.

Understanding these misconceptions can help individuals feel more comfortable and informed when using the Planned Parenthood Proof form.

↓ Planned Parenthood Proof PDF Form

Key takeaways

When filling out and using the Planned Parenthood Proof form, keep these key takeaways in mind:

Print Legibly: Ensure all information is clear and easy to read.
Confidentiality: Your privacy is a priority. Information will be kept confidential, and communication methods will be discussed.
Contact Preferences: Indicate how you prefer to be contacted for test results, such as via phone or mail.
Emergency Contact: Provide a reliable emergency contact name and phone number.
Medical History: Be honest about your medical history and current symptoms to receive the best care.
Understanding Rights: Familiarize yourself with your rights as a patient, including the ability to ask questions.
Interpreter Services: If you need language assistance, inform the staff, but be aware that services may not be immediately available.
Test Results: You can choose a password for receiving test results over the phone for added security.
Consent and Acknowledgment: Sign the form only when you understand and agree to the terms outlined.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is essential to follow certain guidelines to ensure accuracy and efficiency. Here is a list of things you should and shouldn't do:

Do print your information clearly to avoid any misunderstandings.
Do provide accurate contact information for effective communication.
Do check the appropriate boxes for contact methods and test results preferences.
Do indicate your preferred pronoun to ensure respectful communication.
Do disclose any relevant medical history or symptoms honestly.

Don't leave any required fields blank; this can delay your service.
Don't provide false information, as it can affect your care and treatment.
Don't hesitate to ask questions if you do not understand any part of the form.
Don't ignore the confidentiality statement; your privacy is important.

Planned Parenthood Proof Preview

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 _____________________________________________________