The Planned Parenthood Proof form is a crucial document designed to facilitate medical services at Planned Parenthood locations. It collects essential personal information, medical history, and preferences regarding communication, ensuring that clients receive tailored care in a respectful and confidential manner. To begin your journey, fill out the form by clicking the button below.
The Planned Parenthood Proof form serves as a critical document for individuals seeking medical services related to pregnancy testing and reproductive health. This form is designed to collect essential personal information, including the patient’s name, contact details, and medical history. It ensures that patients are informed of their rights and responsibilities while also addressing confidentiality and privacy concerns. Patients are asked to indicate their preferred methods of communication for receiving test results, which may include phone calls or mail. The form also includes sections for medical screening, allowing individuals to specify their reasons for testing, symptoms they may be experiencing, and any relevant medical history. Furthermore, the assessment section, completed by clinic staff, provides a structured way to record test results and patient education provided during the visit. By requiring a signature, the form acknowledges the patient's understanding of the services offered and the privacy practices in place, reinforcing the importance of informed consent in healthcare. Overall, the Planned Parenthood Proof form facilitates a comprehensive approach to patient care, ensuring that individuals receive the necessary information and support throughout their healthcare journey.
When seeking services from Planned Parenthood, several key documents complement the Planned Parenthood Proof form. These documents help ensure that patients receive the necessary information and consent for their care. Here’s a brief overview of four important forms often used alongside the Planned Parenthood Proof form.
These documents work together to facilitate a comprehensive and respectful healthcare experience. By understanding each form's purpose, patients can engage more fully in their care and make informed decisions about their health.
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 _____________________________________________________
Filling out the Planned Parenthood Proof form is a straightforward process that requires careful attention to detail. This form collects essential information to ensure that you receive the appropriate medical services. After completing the form, it will be submitted to the clinic, where staff will review your information and proceed with the necessary services.
The Patient Information Form is similar to the Planned Parenthood Proof form in that it collects essential demographic and health information from patients. It typically includes sections for the patient's name, address, contact information, and medical history. Like the Proof form, it emphasizes the importance of accurate information to ensure proper medical care. Both forms also require the patient to acknowledge their understanding of rights and responsibilities, reinforcing the importance of informed consent in healthcare settings.
The Consent for Treatment Form shares similarities with the Planned Parenthood Proof form by detailing the patient's consent for medical services. This document outlines the procedures, benefits, and potential risks associated with treatments, mirroring the Proof form's intent to ensure patients are well-informed. Both forms require a signature from the patient, indicating that they understand the information presented and agree to proceed with the recommended care.
The Medical History Questionnaire is another document that aligns with the Planned Parenthood Proof form. It gathers comprehensive information about a patient's past medical history, current medications, and any allergies. Like the Proof form, it aims to provide healthcare providers with critical information that can influence treatment decisions. Both documents prioritize patient safety and effective communication between the patient and healthcare provider.
The Release of Information Form is comparable to the Planned Parenthood Proof form in that it addresses patient confidentiality and the sharing of medical information. This document allows patients to authorize the release of their health records to other healthcare providers or entities. Similar to the Proof form, it highlights the importance of maintaining confidentiality while ensuring that necessary information can be shared for continuity of care.
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Finally, the Financial Responsibility Agreement is akin to the Planned Parenthood Proof form as it outlines the patient's obligations regarding payment for services rendered. This document clarifies the financial aspects of care, including potential costs and payment methods. Like the Proof form, it requires the patient's acknowledgment and signature, ensuring that they understand their financial responsibilities before receiving treatment.
Acord 130 - This form helps create a clear line of communication between the underwriter and the applicant.
For those engaged in buying or selling an ATV in California, having the correct documentation is key, and the California ATV Bill of Sale form is an indispensable part of this process. This document not only acts as a receipt but also contains vital details that protect both the buyer and seller during the transaction. To streamline your ATV transfer, you can access and complete the form by visiting https://californiapdfforms.com/atv-bill-of-sale-form.
How Do Apartments Verify Rental History - Verification form aims to assist in future rental decisions.
Understanding the Planned Parenthood Proof form is crucial for patients seeking medical services. However, several misconceptions often arise. Here are ten common misunderstandings, along with clarifications to promote accurate knowledge.
By addressing these misconceptions, individuals can approach their healthcare with greater confidence and clarity. Understanding the Planned Parenthood Proof form is a step towards informed health decisions.