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Fill Out Your Planned Parenthood Proof Form

The Planned Parenthood Proof form is a crucial document that individuals complete when seeking medical services related to pregnancy testing and other reproductive health services. It collects personal information, medical history, and consent for care while ensuring the confidentiality and privacy of the individual. Understanding this form is essential for anyone looking to access Planned Parenthood services, so please fill it out by clicking the button below.

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Fill Out Your Planned Parenthood Proof Form

Article Structure

The Planned Parenthood Proof form serves as a comprehensive document that facilitates the initial assessment of individuals seeking medical services related to pregnancy testing and related reproductive health care. This form ensures the collection of essential personal information, including contact details, employer information, and medical history. Patients are required to indicate their preferred method of communication for receiving test results and can customize their experience by selecting pronouns and specifying preferred contact methods. The form also includes a detailed medical screening section, where clients are prompted to disclose critical information regarding their menstrual cycle, any symptoms experienced, current birth control usage, and potential past experiences related to reproductive health challenges. Additionally, it addresses concerns surrounding confidentiality and informs patients about their rights, including access to interpreter services, the ability to ask questions, and the importance of providing accurate medical information. The form requires the patient's acknowledgment of the Notice of Health Information Privacy Practices, reinforcing the commitment to privacy and informed consent. By capturing this information, the Planned Parenthood Proof form aims to create a supportive environment for patients as they navigate their reproductive health options.

Planned Parenthood Proof Example

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 _______________

Get Planned Parenthood Proof PDF Form

Form Characteristics

Fact	Description
Location	Planned Parenthood of Southeastern Virginia has two locations: Hampton (403 Yale Drive) and Virginia Beach (515 Newtown Road).
Purpose	The form is used for individuals seeking a urine pregnancy test, ensuring that patients provide necessary information for accurate testing.
Confidentiality	Patients' confidentiality is prioritized, with specific methods outlined for how results and sensitive information may be communicated.
Patient Rights	Patients must acknowledge receiving a copy of the Patient’s Bill of Rights and Responsibilities, ensuring that they are informed of their rights.
Emergency Reporting	If certain sexually transmitted infections test positive, reporting to public health agencies is required by law, as mandated by Virginia health regulations.
Interpretive Services	Patients are informed about the availability of language interpreter services when needed for understanding healthcare information.

Guidelines on Utilizing Planned Parenthood Proof

Completing the Planned Parenthood Proof form accurately is essential to ensure that the relevant medical services can be provided to the patient in a timely manner. Each section of the form gathers specific information needed to facilitate appropriate care and maintain confidentiality. Follow these steps carefully to fill out the form correctly.

Read the Instructions: Before filling out the form, take a moment to read any instructions provided at the top of the page. This will guide you through the process and ensure all necessary information is included.
Check the Box: Mark the checkbox next to "URINE PREGNANCY TEST" to indicate the service you are seeking.
Provide Personal Information: Fill out your last name, first name, and middle initial in the designated spaces. Also, complete your address, including apartment number, city, state, and zip code.
Include Employment Details: Enter your employer's name and your email address (note that this cannot be used for test results).
Contact Information: Provide your home phone number, cell phone number, and work phone number. Identify an emergency contact and their phone number.
Choose Contact Methods: Check the methods through which you prefer to receive results, such as phone call or mail. Provide a password if you want to receive test results over the phone.
Fill in Demographic Information: Include your date of birth, sex, monthly income, family size, and preferred pronoun.
Specify Living Will Status: Indicate whether you have a living will by checking “Yes” or “No.”
Indicate How You Heard About Planned Parenthood: Check the appropriate box or write in other sources as needed.
Provide Race and Ethnicity Information: Select your race and indicate if you are Hispanic by checking “Yes” or “No.”
Educate Yourself on Medical Screening: Complete the medical screening section by providing the first day of your last menstrual period, indicating if it was normal, and stating the reason for your test.
Address Current Symptoms and History: Answer questions regarding any current symptoms, birth control use, and medical history honestly.
Assessment Section: Leave this section blank as it will be completed by clinic staff during your visit.
Signatures: Provide your signature and date where indicated, confirming you understand the provided information. If applicable, have a witness sign as well.

After completing the form, it is important to review all entries for accuracy before submitting it to the clinic staff. The information collected will contribute to your care process, ensuring that you receive appropriate services tailored to your needs.

What You Should Know About This Form

What is the Planned Parenthood Proof form?

The Planned Parenthood Proof form is a document necessary for individuals seeking medical services at Planned Parenthood of Southeastern Virginia. It includes essential information such as personal identification, financial details, and medical history. This form helps the clinic maintain accurate records and ensures that patients receive the appropriate care tailored to their needs.

How do I fill out the Planned Parenthood Proof form properly?

When filling out the Planned Parenthood Proof form, it's important to write legibly to avoid any errors in your medical records. Begin with your personal details, including your full name and contact information. Self-disclosure regarding your income, family size, and medical history is also essential. Be thorough, especially when answering medical screening questions, as this information will help the healthcare staff provide you with suitable services.

What should I do if I have questions while filling out the form?

If you have any questions while completing the Planned Parenthood Proof form, you should reach out to the clinic staff for assistance. It’s vital to understand everything you’re filling out, especially regarding your medical history and consent sections. The staff is available to explain any part of the document and ensure you feel comfortable with the information you provide.

How does Planned Parenthood ensure my confidentiality when I submit this form?

Planned Parenthood of Southeastern Virginia takes patient confidentiality very seriously. The information provided on the Proof form is used solely for medical purposes and is protected according to privacy practices. Communication regarding your results and medical information may occur through various secure methods, but you always have control over how you wish to be contacted.

What should I do if I require assistance in a different language?

If you require assistance in a language other than English, you should inform the clinic staff when you arrive. They will work to provide the necessary interpretation services. It’s also advised to communicate any needs for these services as soon as possible to ensure staff can meet your requirements without delays.

What if I want to change the information I provided on the form?

If you need to change any information on the Planned Parenthood Proof form after submitting it, contact the clinic as soon as you can. You have the right to update your information, especially regarding health history, income, or contact methods. Keeping the staff informed ensures that your medical care remains accurate and effective.

Common mistakes

Completing the Planned Parenthood Proof form accurately is crucial for ensuring you receive the appropriate care and services. However, individuals often make mistakes that can lead to delays or issues in processing. One common mistake is not printing information legibly. The form explicitly requests that all entries be made clearly. When information is difficult to read, it creates confusion and can postpone essential communications such as test results.

Another frequent error involves failing to provide accurate contact information. The form requests multiple contact methods, such as home phone, cell phone, and email. Omitting or incorrectly entering this information can result in missed calls or messages regarding your health status. Ensuring your contact details are correct allows the clinic to reach you timely, especially when receiving test results, which may require urgent attention.

Many people overlook the importance of selecting their preferred method of contact. The form allows for choices such as phone calls or mail, but failing to check one of these options can lead to unwanted delays or misunderstandings regarding your test outcomes. Patients should take a moment to ensure they check their preferred contact method; otherwise, they may face unnecessary anxiety waiting for news.

Lastly, individuals sometimes neglect to answer all questions or complete required sections, especially in the medical screening part of the form. Incomplete information can hinder the clinic’s ability to provide effective care and may lead to additional questions or follow-up visits. Patients must remember that thoroughness is vital; providing complete answers helps ensure that their care is personalized and comprehensive.

Documents used along the form

The Planned Parenthood Proof form serves as a vital document for clients seeking services related to reproductive health. Along with it, several other forms and documents are often utilized to ensure a comprehensive understanding of the services and privacy practices involved. Here are a few key documents commonly associated with the Planned Parenthood Proof form:

Request for Medical Services: This document formally requests the medical services needed by the client. It outlines the client's rights and responsibilities, ensuring they understand what services they are consenting to receive.
Acknowledgement of Receipt of Health Information Privacy Practices: This form confirms that clients have received and understood the health information privacy practices. It highlights the importance of confidentiality in handling personal health information.
Medical History Questionnaire: A detailed questionnaire documenting the client’s medical history, current medications, and health conditions. This information is crucial for healthcare providers to assess risks and provide appropriate care.
Informed Consent Form: This form ensures that clients are fully aware of the risks, benefits, and alternatives associated with the procedures or treatments they may receive. It emphasizes the client's right to ask questions and make informed choices regarding their health.

These documents collectively play an integral role in delivering safe, respectful, and patient-centered care at Planned Parenthood. Clients are encouraged to familiarize themselves with each form to ensure they receive comprehensive services that align with their health needs.

Similar forms

Informed Consent Form: Both documents require patients to acknowledge understanding of their rights and the procedures involved in their care. They highlight the importance of clear communication and informed decision-making about medical treatments and services.
Patient Privacy Notice: Similar to the Planned Parenthood Proof form, this document outlines the confidentiality of patient information and the protocols for how health information may be used and shared, emphasizing privacy rights.
Health History Questionnaire: Like the Planned Parenthood Proof form, this document collects personal and medical information from patients to ensure appropriate care. It also assesses risk factors and relevant medical history.
Patient Rights and Responsibilities Document: This document parallels the Planned Parenthood Proof form in that it informs patients of their rights within the healthcare system, including the right to make requests about their care and a commitment to non-discrimination.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it's important to approach it thoughtfully and carefully. Here’s a helpful list of dos and don'ts to guide you.

Do print clearly and legibly. This ensures that your information is correctly processed.
Do double-check your personal details for accuracy, including your full name, address, and contact information.
Do read through each section before providing your answers; understanding what is being asked can help avoid mistakes.
Do be honest about your medical history and current circumstances. This is crucial for your care.

Don't leave any required fields blank. Missing information can delay your appointment or services.
Don't use your email address for receiving test results, as specified. Follow the indicated instructions.
Don't hesitate to ask staff if you have questions about any part of the form. They are there to help you!
Don't rush through the form. Take your time to ensure everything is accurate and complete.

Misconceptions

Many people hold misconceptions about the Planned Parenthood Proof form. Understanding these misconceptions is essential for ensuring informed choices and fostering trust in healthcare services.

The form is strictly for obtaining medical services. In reality, the form serves multiple purposes, including providing important personal information and obtaining consent for medical services. It also facilitates effective communication and care tailored to the individual's needs.
Only women need to fill out this form. This is incorrect. While it often pertains to women's health services, individuals identifying as transgender or non-binary may also seek care at Planned Parenthood. The form is inclusive and accommodates diverse gender identities.
Privacy cannot be guaranteed. Many individuals fear that their information will not remain confidential. However, Planned Parenthood emphasizes maintaining confidentiality as described in their notice of health information privacy practices. Trust in that commitment is crucial when seeking care.
The form is overly complex and difficult to understand. Although it may initially appear detailed, most sections are straightforward. Planned Parenthood encourages individuals to ask questions if they have uncertainty about any portion of the form, ensuring clarity and understanding.
Providing income information is unnecessary. It is important to provide accurate income details as this information can affect eligibility for certain programs or services. Understanding one's financial situation can help providers recommend the most appropriate options for care.

Clearing up these misconceptions can help individuals make informed decisions regarding their healthcare and understand their rights when interacting with Planned Parenthood services.

Key takeaways

Ensure Clarity: It is essential to fill out the Planned Parenthood Proof form using clear and legible printing. This helps avoid misunderstandings and errors in processing.
Contact Method Preference: Indicate your preferred methods of communication for receiving test results. Choose between phone calls or regular mail, and provide a password for phone inquiries.
Accurate Medical History: Fill in details about your medical history and current symptoms accurately. This information is crucial for receiving appropriate care.
Understanding Your Rights: You should acknowledge receipt of the Patient's Bill of Rights and Responsibilities, which ensures you are aware of your rights during the care process.
Emergency Contact Information: Provide a reliable emergency contact name and phone number. This could be vital in case of unforeseen medical issues.
Educational Background: The form prompts you to disclose your highest level of education completed. This information can assist staff in tailoring communications about your health care.
Consent to Treatment: Understand that by signing the form, you consent to evaluations, testing, and recommended treatments. It is your right to ask questions before giving consent.
Stay Informed: Before consenting to any services, ask questions if any part of the form or related information is unclear. It’s vital to fully understand your medical options and rights.

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