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Blank Planned Parenthood Proof Form

The Planned Parenthood Proof form serves as a crucial document for individuals seeking reproductive health services, particularly those undergoing urine pregnancy tests. This form captures essential personal information, medical history, and preferences related to communication, ensuring that the patient’s needs and rights are prioritized. By clearly outlining the services provided and necessary acknowledgments, the form fosters a respectful and informed healthcare experience.

Contents

When seeking healthcare, especially related to reproductive health, clarity and understanding are paramount. The Planned Parenthood Proof form is an essential document that helps streamline the process for individuals seeking services at Planned Parenthood of Southeastern Virginia. This form collects vital information such as personal details, medical history, and contact preferences to ensure a tailored and confidential experience. Patients are prompted to check their preferred methods of communication for receiving test results, allowing for flexibility and comfort. Additionally, the form incorporates important sections covering medical screenings, including details about menstrual history and pregnancy symptoms. It also includes sections for assessing any potential risks related to interpersonal relationships, fostering a safe space for addressing sensitive topics. Overall, the Planned Parenthood Proof form serves not just as an administrative tool, but also as a first step in empowering individuals to take control of their health and well-being.

Sample - 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 _______________

Click for PDF

Form Information

Fact Name	Description
Provider Information	The form is from Planned Parenthood of Southeastern Virginia, with locations in Hampton and Virginia Beach.
Contact Methods	Patients can choose how they wish to be contacted regarding test results, including phone calls and mail.
Patient's Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities, ensuring they are aware of their rights in the healthcare setting.
Confidentiality Assurance	The form emphasizes the commitment to maintaining patient confidentiality through various communication methods.
State Compliance	This form aligns with Virginia state health care regulations, which require informed consent and confidentiality in medical practices.

Detailed Guide for Filling Out Planned Parenthood Proof

Completing the Planned Parenthood Proof form is an important step for those seeking medical services. It requires personal information, details about previous medical history, and consent for various communications. Your thoughtful approach to filling out this form helps ensure that your needs are understood and addressed effectively.

Gather Required Information: Before starting, collect details about your personal information including your full name, address, contact numbers, and email address.
Review Privacy Policies: Ensure you have read the Patient’s Bill of Rights and Responsibilities and Complaint Policy, as you will need to confirm that you have received a copy.
Personal Details: Fill in your last name, first name, and middle initial. Then, proceed to provide your address, apartment number (if applicable), city, state, and zip code.
Employment Information: Provide your employer's name and your email address. Note that your email will not be used for test results.
Contact Information: Include all relevant phone numbers: home, cell, and work. Also, list an emergency contact name and phone number.
Communication Method: Decide how you prefer to be contacted regarding test results. Make sure to check the appropriate boxes for phone calls or mail.
Set a Password: Create a password for verification when you receive test results over the phone.
Demographics: Fill in your date of birth, sex, and monthly income. Include your family size and preferred pronoun.
Living Will: Indicate whether you have a living will by checking the appropriate box.
Referral Information: Mark how you heard about Planned Parenthood, choosing from the provided options.
Complete Additional Information: Provide details related to your race, ethnicity, and highest level of education completed.
Medical History: Record the first day of your last menstrual period and whether it was normal. Check any symptoms you are currently experiencing and indicate if you are using birth control.
Health Assessment: Answer questions about your medical history and experiences, such as abortion history or signs of pregnancy.
Sign and Date: After reviewing all your information, sign and date the form. If a guardian is required to sign, ensure they do so and that a witness signs as well.

Obtain Answers on Planned Parenthood Proof

What is the Planned Parenthood Proof form?
The Planned Parenthood Proof form is a document that patients fill out to access medical services at Planned Parenthood Southeastern Virginia. It includes personal information, medical history, and consent for treatment. This form helps ensure that the staff has necessary information for providing care, including details about pregnancy tests, contraception methods, and any pertinent medical conditions.
How is my information protected?
Confidentiality is a top priority at Planned Parenthood. Your personal and medical information will be kept private and handled according to health privacy laws. The form explicitly states that, while communication methods may include phone calls or mail, your contact methods will be limited to what you approve. Any sensitive information shared will be treated with the utmost discretion by the staff.
What happens if I have questions about the form?
If you have questions or concerns while filling out the form, you are encouraged to speak with a clinic staff member. They are available to clarify any aspects of the form and ensure that you understand everything. It’s important to feel comfortable and informed about what you are consenting to, so don’t hesitate to ask for assistance.
Do I have to provide all the information requested on the form?
While it is essential to provide accurate information for your care, you have the right to determine what personal details you disclose. However, some information may be critical for ensuring appropriate medical services. If you are uncomfortable providing certain details, it is best to discuss this with clinic staff, who can guide you on what is necessary for your treatment while respecting your privacy.

Common mistakes

Filling out the Planned Parenthood Proof form can feel like a daunting task. It is essential to take your time and avoid common mistakes to ensure your information is accurate. One frequent error is inadequate legibility. If your handwriting is hard to read, it can lead to misunderstandings and delays. Always print clearly, as it is vital for your health care provider to have accurate contact information and personal details.

Another mistake is skipping sections of the form. Each part of the form serves a purpose. For instance, failing to complete the emergency contact information could hinder communication in a critical situation. Review the entire form before submitting, making sure that you haven't overlooked any required fields.

People also often forget to provide a password for test results via phone. This can slow down the process of receiving your results. Include a specific password so staff can verify your identity when they call.

Assuming that previous health information is still relevant can lead to incorrect assessments. Regularly update your medical history and ensure that you explicitly indicate any changes in your condition or treatments on the form.

Another common oversight is selecting the wrong methods of contact. Carefully consider how you would prefer to receive updates and results. Choosing a method that is inconvenient for you can create unnecessary stress, especially if urgent communication is needed.

Providing inaccurate information regarding household income could affect eligibility for financial assistance or services. It’s crucial to report this data as honestly as possible to avoid issues later on.

Additionally, misunderstanding questions about past medical history is common. Make sure you read each question thoroughly and respond accurately. Misrepresentation can lead to inappropriate treatment recommendations.

Lastly, neglecting to ask questions about anything unclear can leave you feeling uneasy about your care. If something on the form is confusing, don’t hesitate to ask staff for clarification. It’s better to have a complete understanding than to guess and potentially fill out the form incorrectly.

Documents used along the form

When visiting a Planned Parenthood facility, you may come across other important forms and documents in addition to the Planned Parenthood Proof form. These documents help ensure that your care is comprehensive and that your rights and privacy are respected. Here are some commonly used forms:

Patient’s Bill of Rights and Responsibilities: This document outlines your rights as a patient and the responsibilities you should be aware of. It serves as a guide to understanding the services you can expect and the standards of care provided.
Acknowledgment of Receipt of Notice of Health Information Privacy Practices: This form provides information about how your health information is protected. You acknowledge that you have received this notice and understand your privacy rights concerning your medical information.
Request for Medical Services: This form allows you to consent to receive services from Planned Parenthood. It includes details about the nature of the medical care you are seeking, and it emphasizes that you have the right to ask questions and change your mind at any time.
Medical History Questionnaire: This form collects vital information about your medical history, including any past procedures, current medications, and relevant health issues. Providing this information helps healthcare providers tailor your care to your needs.

These forms are essential for a smooth experience at Planned Parenthood. They ensure that both you and the healthcare staff are on the same page regarding your care, rights, and privacy. Remember that asking questions and understanding these documents is always your right.

Similar forms

The Planned Parenthood Proof form shares similarities with several other documents related to healthcare and patient consent. Each of these documents serves a critical role in ensuring informed decision-making and the protection of patient rights.

Informed Consent Form: This form outlines the specifics of a medical procedure or test, including its purpose, risks, and benefits. Like the Planned Parenthood Proof form, it requires a patient's acknowledgment that they understand the information before proceeding.
Patient Registration Form: Similar to the Planned Parenthood Proof form, this document gathers essential patient information, such as demographics and insurance details, to create a complete medical record for healthcare providers.
HIPAA Privacy Notice: This document explains how a patient's health information will be used and shared. Both documents emphasize the importance of patient confidentiality and provide patients with rights regarding their personal health information.
Release of Information Form: This form allows healthcare providers to share a patient’s medical records with other entities, which can mirror certain aspects of consent featured in the Planned Parenthood Proof form. Both documents ensure that patients are aware of and authorize the sharing of sensitive information.
Emergency Contact Form: This document collects emergency contact details, similar to the contact information section in the Planned Parenthood Proof form. Both forms aim to ensure that healthcare providers can reach relatives or friends in urgent cases.
Health History Questionnaire: Like the Planned Parenthood Proof form, this questionnaire gathers information about a patient's past medical history and current health status, enabling better care decisions by the healthcare team.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, ensuring accuracy and clarity is vital. Here are some key points to keep in mind:

Do print legibly: Clear handwriting is crucial. It helps staff understand your information without confusion.
Don’t leave blanks: Every section should be filled out to the best of your ability. Incomplete forms may delay your service.
Do provide a reliable contact method: Indicate how you prefer to receive important information, whether through phone, mail, or another means.
Don’t hesitate to ask questions: If you are unsure about any part of the form or process, feel free to seek clarification from the staff.

Misconceptions

Misconception 1: The Planned Parenthood Proof form is only for women.

This form is designed for anyone who may need reproductive health services, including transgender individuals and non-binary people. Gender-inclusive language is used to ensure everyone feels welcome and understood.

Misconception 2: Signing the form means you have to undergo a procedure or testing.

Signing the form simply gives consent for evaluation and education about available options. You can choose to opt-out of any services without any penalties.

Misconception 3: My information will be shared with outside parties.

Confidentiality is a top priority. The information provided is kept private and will only be shared in accordance with privacy laws or your explicit consent.

Misconception 4: You must provide your email address for test results.

While the form requests an email address, it cannot be used for delivering test results. This is to protect your privacy. Other contact methods like phone or mail can be used instead.

Misconception 5: You cannot change your mind once you've signed the form.

You have the right to change your mind at any time regarding the services you choose to receive. Your autonomy and comfort are paramount.

Misconception 6: A living will is required to receive services.

A living will is optional. It is included on the form simply to gather information that may help in your care, but it is not a requirement for services.

Misconception 7: All staff members involved in care are licensed medical professionals.

Planned Parenthood Southeastern Virginia is a teaching institution. This means that trainees may assist in care under supervision. Nonetheless, licensed professionals ensure that you receive quality services.

Key takeaways

Filling out the Planned Parenthood Proof form is an important step in ensuring you receive the medical services you need. Here are some key takeaways to help you navigate the process effectively:

Print Legibly: Make sure to print your information clearly to avoid any confusion or errors in your medical records.
Provide Accurate Information: It is essential that all the information you provide, such as your address and medical history, is truthful and complete. This will help the clinic offer you the best care possible.
Choose Contact Preferences: Indicate how you prefer to be contacted regarding your test results. Options include phone calls or mail, but ensure that you are comfortable with the methods chosen.
Emergency Contact: List an emergency contact person and their phone number. This information is crucial in case of any urgent situations.
Understanding Your Rights: Before signing, be aware of your rights as a patient, including the option to ask questions about your treatment and seek interpretive services if needed.
Stay Informed: Questions can arise regarding procedures, tests, or treatments. Don’t hesitate to ask clinic staff for clarification to ensure you fully understand what to expect.
Confidentiality Assurance: Be reassured that your information will be kept confidential, as per the Planned Parenthood privacy practices. Understanding this can help alleviate concerns about sharing sensitive information.

By following these guidelines, you can help ensure that you complete the Planned Parenthood Proof form smoothly and receive the care needed for your health concerns.

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