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Fill a Valid Planned Parenthood Proof Form

The Planned Parenthood Proof form is a vital document used to collect essential information from patients seeking medical services. This form ensures that individuals receive the necessary care while maintaining their confidentiality and understanding of the procedures involved. If you’re ready to take the next step, please fill out the form by clicking the button below.

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Fill a Valid Planned Parenthood Proof Form

Contents

The Planned Parenthood Proof form serves as an essential document for individuals seeking medical services related to pregnancy testing and reproductive health. This form collects vital information, such as personal details, contact preferences, and medical history, ensuring that patients receive the most appropriate care. It includes sections for demographic data, income, and education, which help the clinic understand the patient's background. The form also addresses confidentiality, outlining how the clinic will communicate test results and other sensitive information. Patients are asked to indicate their preferred contact methods and provide a password for receiving results over the phone. Additionally, the form includes a medical screening section that helps assess the patient's current health status and any potential issues related to pregnancy. Overall, the Planned Parenthood Proof form is designed to facilitate a smooth and respectful experience for patients while ensuring their needs and rights are prioritized.

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Document 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 _______________

Form Specs

Fact Name	Details
Organization	Planned Parenthood of Southeastern Virginia
Locations	403 Yale Drive, Hampton, VA 23666; 515 Newtown Road, Virginia Beach, VA 23462
Contact Numbers	(757) 826-2079; (757) 499-7526
Test Type	Urine Pregnancy Test
Patient's Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities.
Confidentiality Commitment	Planned Parenthood is committed to maintaining patient confidentiality.
Contact Methods	Patients can choose to be contacted by phone or mail regarding test results.
Medical Screening	Includes questions about menstrual history, pregnancy symptoms, and birth control usage.
Legal Compliance	Reporting of positive test results for certain sexually transmitted infections is required by law.

Crucial Questions on This Form

What is the Planned Parenthood Proof form?

The Planned Parenthood Proof form is a document used by patients seeking medical services at Planned Parenthood of Southeastern Virginia. It collects essential information such as personal details, medical history, and preferences for communication regarding test results. This form helps ensure that the healthcare staff can provide appropriate care while maintaining patient confidentiality.

Why do I need to provide my personal information?

Providing personal information is crucial for several reasons. It helps healthcare providers understand your medical history and current situation, ensuring you receive the best possible care. Additionally, your contact information allows Planned Parenthood to reach you with important updates, including test results. Your confidentiality is a top priority, and the information you share is protected by privacy laws.

What should I do if I have questions about the form?

If you have questions about the form or any part of the process, don’t hesitate to ask. Planned Parenthood staff are available to help clarify any details. It's important that you fully understand the information before signing. You can ask for a copy of the form to review at your own pace.

How will I receive my test results?

Test results will be communicated to you through the method you select on the form. You can choose to receive results via phone call or mail. If you prefer a phone call, you will need to provide a password for added security. This ensures that only you can access your results, protecting your privacy.

What if I need an interpreter for the form?

If you require language interpreter services to understand the form, it's essential to inform the staff. While Planned Parenthood aims to provide these services, they may not always be immediately available. In such cases, they may refer you to another facility that can assist you. Your understanding of the information is vital for informed decision-making.

What happens if I change my mind about receiving services?

You have the right to change your mind at any point during the process. If you decide not to proceed with the services, you can simply inform the staff. Your comfort and consent are paramount, and you should never feel pressured to continue if you are unsure.

Documents used along the form

When seeking services from Planned Parenthood, there are several other forms and documents that may accompany the Planned Parenthood Proof form. Each of these documents serves a specific purpose and helps ensure that patients receive the appropriate care and information. Below is a list of commonly used forms that you may encounter.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights patients have when receiving care, as well as the responsibilities they hold. It is designed to empower patients and ensure they understand their entitlements in the healthcare setting.
Patient Complaints Policy: This policy provides information on how patients can voice concerns or complaints regarding their care. It establishes a clear process for addressing issues, ensuring that patients feel heard and respected.
Request for Medical Services: This form is used by patients to formally request medical services. It includes consent for treatment and acknowledges that patients understand the information provided about their care options.
Acknowledgement of Receipt of Notice of Health Information Privacy Practices: This document confirms that patients have received and understood the privacy practices regarding their health information. It is crucial for maintaining confidentiality and trust.
Trailer Bill of Sale: This legal document is essential for recording the sale of a trailer in Georgia, ensuring a smooth transaction and protecting both parties involved. For more details, visit https://georgiapdf.com/trailer-bill-of-sale.
Medical History Form: Patients may be asked to fill out a medical history form, which collects important information about their past health issues, medications, and family medical history. This helps healthcare providers deliver personalized care.
Consent for Treatment: This form is necessary for patients to give their informed consent before receiving specific treatments or procedures. It ensures that patients understand the risks and benefits associated with their choices.
Emergency Contact Form: This document allows patients to designate someone to be contacted in case of an emergency. It is an important part of ensuring that patients receive timely support if needed.

Each of these documents plays a vital role in the healthcare process at Planned Parenthood. They help facilitate communication, ensure informed consent, and protect patient rights. Understanding these forms can enhance the overall experience and ensure that individuals receive the care they need with dignity and respect.

Misconceptions

Here are some common misconceptions about the Planned Parenthood Proof form:

It is only for women. Many people think this form is exclusively for women, but it is designed for anyone seeking reproductive health services, including transgender individuals.
Providing personal information is unnecessary. Some believe that sharing personal details, like income or education level, is not important. However, this information helps the clinic tailor services to meet individual needs.
Test results are only communicated through email. There is a misconception that results can only be sent via email. In fact, the clinic may contact patients through phone calls or mail, ensuring confidentiality.
All tests are free. Many assume that all services and tests are free of charge. While some services may be low-cost or free, others may require payment or insurance coverage.
Consent is permanent. Some individuals think that once they consent to services, they cannot change their minds. In reality, patients can withdraw consent at any time before receiving services.
The form guarantees specific outcomes. It is a common belief that completing the form ensures a particular result, such as a negative pregnancy test. However, the form does not guarantee any outcomes from the tests.
Confidentiality is not prioritized. Many people doubt that their information will be kept private. Planned Parenthood is committed to maintaining confidentiality as outlined in their privacy practices.