Fill Out a Valid Planned Parenthood Proof Form

The Planned Parenthood Proof form is a document used to gather essential information from patients seeking medical services, particularly related to pregnancy testing. This form ensures that individuals understand their rights and responsibilities while maintaining confidentiality. By completing this form, patients can facilitate their care and receive the necessary support from healthcare professionals.

Access This Planned Parenthood Proof Now

The Planned Parenthood Proof form is an essential document designed to facilitate the medical services provided by Planned Parenthood of Southeastern Virginia. This form collects vital information from patients, including personal details such as name, address, and contact information, while ensuring a commitment to confidentiality throughout the process. Patients are asked to indicate their reason for testing, which may include planned pregnancy or contraceptive failure, and to provide medical history that can influence their care. The form also addresses important topics such as birth control methods, emergency contacts, and even personal preferences regarding communication. By gathering this information, the staff can better understand each patient's unique situation and offer tailored support. The form emphasizes the importance of informed consent, ensuring that patients are aware of their rights and the potential risks and benefits associated with their healthcare choices. Ultimately, this thorough approach aims to create a safe and supportive environment for individuals seeking reproductive health services.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is essential to ensure that all information is accurate and complete. Here are some important do's and don'ts to consider:

Do print legibly to ensure clarity and avoid misunderstandings.
Do provide accurate contact information, as this will be used for important communications regarding your health.
Do check all applicable boxes carefully to ensure your preferences and needs are clearly communicated.
Do read the Patient’s Bill of Rights and Responsibilities before signing, so you understand your rights.
Don't leave any sections blank; incomplete forms can delay your care.
Don't provide false information, as this can lead to complications in your treatment.
Don't hesitate to ask for clarification on any part of the form that you do not understand.

Key takeaways

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

Print Clearly: Always print your information legibly to avoid any confusion or errors in processing.
Confidentiality Matters: Your privacy is important. Indicate how you prefer to be contacted regarding test results.
Be Honest: Provide accurate information about your medical history and current health status. This helps ensure you receive the best care possible.
Understand Your Rights: Familiarize yourself with your rights as a patient, including the ability to ask questions about your care.
Involve Others If Necessary: If you need assistance, such as a language interpreter, communicate this to the staff before your appointment.

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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 _______________

Misconceptions

Understanding the Planned Parenthood Proof form can be challenging due to various misconceptions. Here are four common misunderstandings:

The form is only for women. Many people believe that the form is exclusively for women. In reality, it is designed for anyone seeking services, regardless of gender identity. Transgender individuals can also use this form to access necessary care.
It is mandatory to provide all personal information. Some think that every piece of information requested is mandatory. However, while certain details are essential for providing care, individuals can choose not to disclose specific information if they are uncomfortable.
The contact methods compromise privacy. A common belief is that providing contact methods, like phone or email, will lead to a breach of privacy. Planned Parenthood is committed to maintaining confidentiality and will only use these methods to communicate necessary information, such as test results.
The form is complicated and hard to understand. Many feel overwhelmed by the form's content. In truth, the language is straightforward, and individuals are encouraged to ask questions if anything is unclear. Staff members are available to assist with understanding the form.

Similar forms

The Planned Parenthood Proof form shares similarities with several other important documents that individuals may encounter in healthcare or legal contexts. Here are five documents that are comparable:

Informed Consent Form: Like the Planned Parenthood Proof form, an informed consent form outlines the risks, benefits, and alternatives of a medical procedure. Both documents require the patient’s acknowledgment of understanding before proceeding with care.
Patient Registration Form: This document collects essential personal and contact information, similar to the Planned Parenthood Proof form. It helps healthcare providers maintain accurate records and communicate effectively with patients.
HIPAA Privacy Notice: Just as the Planned Parenthood Proof form emphasizes confidentiality and privacy, the HIPAA Privacy Notice explains how a patient's health information will be used and protected. Both documents prioritize the safeguarding of personal data.
Medical History Form: This form gathers detailed information about a patient’s past health conditions and treatments. The Planned Parenthood Proof form also includes medical screening questions to ensure comprehensive care tailored to the patient’s needs.
Emergency Contact Form: Similar to the Planned Parenthood Proof form, this document requests information about whom to contact in case of an emergency. Both forms are vital for ensuring patient safety and effective communication during healthcare visits.