Printable Planned Parenthood Proof Template

The Planned Parenthood Proof form is a document used by individuals seeking medical services related to pregnancy testing and reproductive health. This form collects essential personal information, medical history, and consent for services while ensuring patient confidentiality. For those interested in receiving care, filling out the form accurately is crucial; click the button below to begin.

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Printable Planned Parenthood Proof Template

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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 collects essential personal information, including the patient's name, contact details, and medical history. It also includes sections for emergency contact information and income details, ensuring that the organization can provide tailored care while maintaining confidentiality. Patients are asked to indicate their preferred methods of communication for receiving test results, which can be vital for timely follow-up. Additionally, the form addresses specific medical screening questions, allowing healthcare providers to assess the patient's current health status and any potential risks. Understanding the context of why the test is being conducted—whether due to a planned pregnancy, contraceptive failure, or other reasons—is also emphasized. The form not only facilitates the medical assessment but also ensures that patients are informed about their rights and the privacy of their health information. Overall, the Planned Parenthood Proof form is designed to streamline the process of receiving care while prioritizing the needs and concerns of each patient.

Common mistakes

Illegible handwriting: It is crucial to fill out the Planned Parenthood Proof form legibly. If the handwriting is unclear, it can lead to misunderstandings or delays in processing your information. Always print clearly to ensure all details are easily readable.
Incomplete information: Leaving out sections of the form can cause significant issues. Ensure that every required field, such as your last name, date of birth, and contact information, is filled out completely. Missing information can delay your appointment or the processing of your test results.
Ignoring contact preferences: It's essential to specify how you wish to be contacted regarding test results. Not checking the appropriate boxes can result in missed communications. Take a moment to consider whether you prefer phone calls or mail, and indicate your choice clearly.
Forgetting the password: When providing a password for receiving test results over the phone, be sure to remember it. This password is a safeguard for your privacy. Without it, staff may be unable to share your results, causing unnecessary anxiety.
Neglecting to ask questions: If anything on the form is unclear, or if you have questions about the information being requested, don’t hesitate to ask for clarification. Understanding the form is vital for your care. Take the time to ensure you fully comprehend each section before submitting.

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Key takeaways

Here are some key takeaways about filling out and using the Planned Parenthood Proof form:

Print Clearly: Make sure to fill out the form legibly. This helps avoid any confusion later.
Contact Methods: Indicate how you prefer to be contacted for test results, either by phone or mail.
Confidentiality: Your privacy is important. Information will be kept confidential, and you can choose how you want to receive updates.
Emergency Contact: Provide the name and phone number of someone who can be contacted in case of an emergency.
Medical History: Be honest about your medical history and current symptoms. This information is vital for your care.
Understanding Consent: Read through the consent section carefully. It explains your rights and what to expect from your care.
Language Services: If you need language assistance, let the staff know. They can help arrange for interpretive services.
Ask Questions: Don’t hesitate to ask questions if anything is unclear. The staff is there to help you.
Follow-Up: If your test results are positive or if you have ongoing concerns, be prepared to discuss further steps and referrals.

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 _______________

Understanding Planned Parenthood Proof

What is the Planned Parenthood Proof form?

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to collect essential information from patients seeking medical services, specifically urine pregnancy tests. It includes personal details, medical history, and consent for treatment.

How do I fill out the form?

To complete the form, please print legibly. Fill in your last name, first name, and middle initial. Provide your address, contact information, date of birth, and other requested details. Be sure to check the appropriate boxes regarding your medical history and reasons for the test.

What information do I need to provide?

Patients must provide the following information:

Personal details (name, address, contact numbers)
Date of birth and sex
Monthly income and family size
Medical history related to pregnancy and birth control
Emergency contact information

How will my confidentiality be maintained?

Planned Parenthood is committed to protecting your privacy. The information you provide will be kept confidential. Communication regarding test results will be done through secure methods, such as phone calls or mail in a plain envelope, based on your preferences.

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

If you have any questions about the form or the information requested, you are encouraged to ask a staff member for assistance. They can provide clarification and ensure you understand the process.

What happens after I submit the form?

Once you submit the form, clinic staff will review your information and conduct the urine pregnancy test. You will be informed about the results and any necessary follow-up actions based on those results.

Can I receive test results over the phone?

Yes, you can receive test results over the phone. However, you must provide a password on the form to ensure your privacy when discussing results with staff.

What if I need interpretive services?

If you require language interpreter services, it is essential to inform the staff before you give your consent. While these services may not always be immediately available, Planned Parenthood will do its best to accommodate your needs.

Is there a cost associated with the services?

Costs may vary depending on the services provided. Patients are encouraged to inquire about fees and payment options during their visit. If referrals for additional care are necessary, patients will be responsible for obtaining and paying for those services.

How to Use Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is a straightforward process that requires accurate information to ensure your needs are met. Follow these steps carefully to complete the form correctly.

Print the form clearly and legibly.
Check the box for the Urine Pregnancy Test.
Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy.
Fill in your last name, first name, and middle initial.
Provide your complete address, including apartment number, city, state, and zip code.
Enter your employer's name and email address (note that email cannot be used for test results).
Include your home phone number, cell phone number, and work phone number.
List the name and phone number of an emergency contact.
Check the preferred methods for Planned Parenthood to contact you: phone call or mail.
Create a password for receiving test results over the phone.
Provide your date of birth and sex.
Indicate your monthly income and family size.
Choose a pronoun you prefer: she or other.
State whether you have a living will (yes or no).
Explain how you heard about Planned Parenthood by checking the appropriate box.
Select your race and ethnicity from the provided options.
Indicate your highest level of education completed.
Complete the medical screening section, including the first day of your last menstrual period and whether it was normal.
State the reason for the test and the results you hope to see.
Answer the questions regarding current experiences, birth control use, and any relevant medical history.
Sign and date the form at the bottom.