The Planned Parenthood Proof form is a document designed 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 confidentiality throughout the process. By providing accurate information, patients can receive appropriate care tailored to their needs.
The Planned Parenthood Proof form serves as a crucial document for individuals seeking medical services, particularly related to pregnancy testing and reproductive health. This form is designed to gather essential personal information, such as the patient's name, contact details, and medical history. It includes sections that allow patients to indicate their preferred methods of communication for receiving test results, ensuring that confidentiality is maintained throughout the process. Additionally, the form addresses important topics like medical screenings, where patients are asked about their last menstrual period and any current symptoms they may be experiencing. The purpose of the test is also clarified, whether it’s for a planned pregnancy, contraceptive failure, or other reasons. Furthermore, the form emphasizes the importance of informed consent, outlining the rights of patients regarding their healthcare choices and the information they will receive about tests and treatments. With a focus on patient education, the form provides guidance on what to expect, including the potential need for follow-up appointments and the importance of discussing any concerns with healthcare providers. Overall, the Planned Parenthood Proof form is an essential tool that facilitates a respectful and informative healthcare experience for individuals navigating their reproductive health needs.
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 _____________________________________________________
The Planned Parenthood Proof form is often accompanied by several other documents that help facilitate patient care and ensure compliance with health regulations. Below is a list of these commonly used forms, each serving a specific purpose in the patient experience.
Each of these documents plays a crucial role in the patient care process, ensuring that patients are informed, their rights are protected, and their health information is managed appropriately.
Whats a W9 Form - The W-9 must be signed and dated by the taxpayer for validation.
The Washington Mobile Home Bill of Sale is a legal document that facilitates the transfer of ownership of a mobile home from one party to another. This form serves as proof of the transaction and outlines important details such as the buyer, seller, and the mobile home’s specifications. You can find a comprehensive example and obtain the necessary form at parkhomebillofsale.com/free-washington-mobile-home-bill-of-sale. Understanding this document is essential for ensuring a smooth and lawful transfer process.
Acord 130 - It requires the agency's name and address handling the application.
How to File a Mechanics Lien - Proper completion and filing are crucial for the enforcement of a Mechanics Lien.
When filling out the Planned Parenthood Proof form, keep these key takeaways in mind:
Being well-informed and careful while completing the Planned Parenthood Proof form can enhance your experience and ensure that you receive the best possible care.
The Planned Parenthood Proof form is primarily used for patients undergoing a urine pregnancy test. It collects essential personal information, medical history, and consent for services. This form ensures that patients are informed about their rights and the procedures involved in their care.
Planned Parenthood is committed to protecting patient confidentiality. They utilize various methods to communicate test results, including phone calls, mail, and text messages, while ensuring that sensitive information is shared securely. Patients are given options to specify their preferred methods of contact, and all communication is handled with discretion.
Patients are required to provide personal details such as:
This information helps the clinic provide tailored care and support based on individual circumstances.
Yes, patients have the right to change their minds about receiving medical services at any point. The form explicitly states that consent can be revoked, allowing patients to make informed decisions about their healthcare without feeling pressured.
If you have questions regarding the Planned Parenthood Proof form or any aspect of your care, you are encouraged to ask the clinic staff for clarification. A clinician is available to address any concerns and ensure that you fully understand the information provided before consenting to services.
Misconceptions about the Planned Parenthood Proof Form