The Planned Parenthood Proof form is a document designed to gather essential information from patients seeking medical services, particularly related to pregnancy testing and reproductive health. This form ensures that individuals understand their rights, the services provided, and the importance of accurate information for their care. For those ready to take the next step, fill out the form by clicking the button below.
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. It includes personal details, medical history, and preferences for communication regarding test results.
To fill out the form, print it legibly. Provide your last name, first name, and middle initial, along with your address, contact numbers, and emergency contact information. You will also need to indicate your reason for the test, any medical history, and your preferences for how you wish to be contacted with results.
You will need to provide details about your menstrual cycle, any current symptoms, and whether you are using birth control. Additionally, the form asks about any past medical issues, such as ectopic pregnancies or miscarriages, and whether you have experienced any abuse related to your reproductive health.
Planned Parenthood is committed to maintaining your confidentiality. They will contact you about test results through the methods you select, such as phone or mail, and will use plain envelopes for correspondence. Your personal information will be handled in accordance with their privacy practices.
Yes, you can choose how you would like to receive your test results. Options include a phone call or mail. If you prefer to receive results over the phone, you will need to provide a password for added security.
If you have any questions while filling out the form or about your care, you are encouraged to ask the clinic staff. They are available to provide clarification and ensure you understand the information presented to you.
If your test results indicate a need for further diagnosis or treatment, Planned Parenthood will provide referrals. You will be responsible for obtaining and paying for any additional care that is required.
While some services may be offered on a sliding scale based on income, it is important to inquire about costs when you make your appointment. You can discuss payment options with the staff during your visit.
If you require language interpreter services, inform the staff before your appointment. While Planned Parenthood will do their best to accommodate your needs, there may be instances where they need to refer you to another facility for these services.
The Planned Parenthood Proof form is an essential document for individuals seeking medical services related to pregnancy testing and reproductive health. Alongside this form, several other documents are frequently utilized to ensure comprehensive care and adherence to privacy practices. Below is a list of these documents, each serving a specific purpose in the healthcare process.
These documents work together to facilitate a supportive and transparent healthcare environment. Each form plays a crucial role in ensuring that patients receive the information they need to 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 an important step for many individuals seeking medical services. However, several common mistakes can lead to delays or complications. One frequent error is failing to print legibly. If the information is hard to read, staff may struggle to contact you or process your request accurately. Always take your time to ensure your handwriting is clear.
Another common mistake is neglecting to provide complete contact information. Omitting your phone number or email can hinder communication about test results or important updates. Make sure to double-check that all fields are filled out correctly, especially the contact methods you prefer.
Many individuals also forget to specify how they heard about Planned Parenthood. This information is valuable for the organization to understand outreach effectiveness. If you leave this section blank, it may seem like you’re not fully engaged in the process.
It's also crucial to answer questions about your medical history honestly. Some people mistakenly think they can skip these sections or provide vague responses. However, accurate medical history helps healthcare providers give you the best care possible. If a question doesn’t apply to you, simply indicate that.
Another mistake involves the emergency contact section. People often either forget to fill it out or provide outdated information. Having a reliable emergency contact ensures that you have support when it’s needed most. Make sure to keep this information current.
Some individuals overlook the importance of selecting a method for receiving test results. Whether it’s by phone or mail, indicating your preference allows for timely communication. Failing to make this choice may delay receiving critical information.
When it comes to providing a password for receiving test results over the phone, many people either leave this blank or forget to create one. This password is essential for verifying your identity and protecting your privacy, so be sure to include it.
Additionally, some patients do not check the boxes regarding their current use of birth control or any symptoms they may be experiencing. This information is vital for your healthcare provider to understand your situation fully. Even if you think it’s not relevant, it’s better to provide more details than less.
Lastly, many people fail to sign and date the form. This is a critical step that confirms you’ve read and understood the information provided. Without a signature, the form may not be considered valid, which could lead to unnecessary delays in your care.
By avoiding these common mistakes, you can help ensure a smoother process when filling out the Planned Parenthood Proof form. Remember, accuracy and completeness are key to receiving the care you need.
Informed Consent Form: Similar to the Planned Parenthood Proof form, an informed consent form outlines the patient's understanding of the treatment, its risks, and benefits. It ensures that patients are fully aware of what they are agreeing to before receiving medical services.
Patient Registration Form: This document collects essential information about the patient, including personal details, contact information, and insurance status. Like the Planned Parenthood Proof form, it helps healthcare providers understand the patient’s background and needs.
Medical History Questionnaire: This form gathers a patient’s past medical history, medications, and allergies. It serves a similar purpose to the Planned Parenthood Proof form by ensuring that healthcare providers have the necessary information to deliver safe and effective care.
Privacy Practices Acknowledgment: This document informs patients about their rights regarding privacy and the handling of their health information. It parallels the Planned Parenthood Proof form in emphasizing the importance of confidentiality in healthcare.
Release of Information Form: This form allows patients to authorize the sharing of their medical records with other healthcare providers. It is similar to the Planned Parenthood Proof form in that it requires patient consent for the disclosure of personal health information.
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