Planned Parenthood Proof PDF Template

The Planned Parenthood Proof form serves as a vital document for individuals seeking medical services related to pregnancy testing and reproductive health. By capturing essential information, this form ensures that patients receive the most accurate care tailored to their specific needs. If you need assistance filling out the form, please click the button below.

Overview

The Planned Parenthood Proof form serves as a vital document for individuals seeking assistance with reproductive health services, particularly for those undergoing urine pregnancy testing. This form is not only a channel for important medical information but also plays a crucial role in ensuring confidentiality and informed consent. Upon completion, users provide essential personal details, including their name, contact information, date of birth, and sexual and reproductive history. The form prompts individuals to indicate their reasons for taking the pregnancy test, any symptoms they may be experiencing, and their contraceptive methods if applicable. Furthermore, it allows for the selection of preferred communication methods for receiving test results, ensuring that individuals feel secure and informed throughout the process. The medical staff also gather information to assess the patient’s overall health and risk factors through a series of screening questions. This comprehensive approach, which includes an acknowledgment of the Patient's Bill of Rights and Responsibilities, emphasizes both the patient’s autonomy and the clinic's commitment to providing safe, respectful care. By ensuring that users are fully informed before consenting to medical services, the Planned Parenthood Proof form establishes a respectful and transparent patient-provider relationship.

Planned Parenthood Proof Preview

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 _______________

↓ Planned Parenthood Proof

File Properties

Fact Name	Detail
Provider Information	Planned Parenthood of Southeastern Virginia operates clinics at two locations: 403 Yale Drive, Hampton, VA 23666 and 515 Newtown Road, Virginia Beach, VA 23462.
Confidentiality Commitment	The organization is dedicated to maintaining patient confidentiality, often through secure communication methods like phone calls and mail.
Methods of Contact	Patients can choose their preferred methods of contact for receiving test results, including phone and mail.
Legal Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities upon request as part of their rights.
Medical Screening Completion	The medical screening section of the form must be completed by the client, providing essential information about their health history and current symptoms.
Urine Pregnancy Test	The form includes a urine pregnancy test with specific instructions on when to take the test and what results can indicate.
State-Specific Laws	In Virginia, laws mandate reporting of positive sexually transmitted infection tests to public health agencies, ensuring public health safety.

Instructions on Utilizing Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is an important step in receiving the services you need. The form requires personal and medical information to facilitate appropriate care. Below are the steps to complete the form accurately.

Begin with the section labeled Personal Information. Write your last name, first name, and middle initial.
Enter your address, including apartment number, city, state, and zip code.
Fill in your employer's name and email address (note that this email cannot be used for test results).
Add your home phone number, cell phone number, and work phone number.
Provide an emergency contact name and phone number.
Mark how you prefer to be contacted regarding your test results: Phone Call or Mail. Provide a password if you would like to receive results over the phone.
Indicate your date of birth and sex, and specify your monthly income and family size.
Choose your preferred pronoun (e.g., She or Other).
Answer whether you have a living will and how you heard about Planned Parenthood.
Select your race and whether you identify as Hispanic.
Specify the highest level of education you have completed.
In the Medical Screening section, fill in the date of your last menstrual period, and indicate if it was normal.
State the reason for your test and your desired test results.
Respond to questions about any current symptoms and whether you are using birth control. If yes, specify the method.
Provide details about any medical history, particularly regarding pregnancy and birth control issues.
Complete the section for Assessment if prompted, including information about urine pregnancy tests and any staff evaluations.
Review the Request for Medical Services section, ensuring you understand the information provided. Sign and date the form as necessary.

Once the form is filled out, you can submit it as per the instructions provided by Planned Parenthood. Remember that staff are available to help with any questions you may have while completing this process.

Important Facts about Planned Parenthood Proof

What is the Planned Parenthood Proof form?

The Planned Parenthood Proof form is a critical document that patients fill out to access services at Planned Parenthood of Southeastern Virginia. It collects essential information related to the patient's personal details, medical history, and reasons for seeking services. This form ensures that healthcare providers can offer the most appropriate care based on accurate information.

Why do I need to provide personal information?

Providing personal information is necessary to establish a patient’s identity, understand their medical history, and facilitate effective communication. Information such as your name, address, and contact details helps ensure confidentiality and allows the clinic to reach you with important results or follow-up care.

Will my information be kept confidential?

Yes, confidentiality is a top priority at Planned Parenthood. The organization has strict policies in place to protect your information. Your data will be used only for your healthcare needs and never shared without your consent. Communication methods, such as phone or mail, will prioritize your privacy.

What should I do if I need interpretive services?

If you require interpretive services due to language barriers, it's important to inform the staff upon arrival. They will arrange for necessary services, although sometimes it may not be available immediately onsite. In such cases, you may be referred to another healthcare facility to ensure you receive the care you need.

Can I change my mind about receiving services?

Absolutely. You have the right to change your mind at any point prior to receiving healthcare services. If you feel uncomfortable or uncertain, do not hesitate to voice your concerns or opt-out. Your comfort and understanding are paramount.

What happens if I have a positive test result for sexually transmitted infections?

If you receive a positive test result for certain sexually transmitted infections (STIs), reporting to public health agencies is mandatory by law. Planned Parenthood will provide you with referrals for further diagnosis and treatment, ensuring you receive appropriate care without compromising your privacy.

How do I provide feedback or report issues?

Feedback is always welcome and can help improve services. If you have any complaints or concerns regarding your experience, feel free to reach out to the staff. Planned Parenthood encourages open communication and will guide you on how to file a formal complaint if needed.

Common mistakes

Many individuals make mistakes when completing the Planned Parenthood Proof form, which can affect their access to services. One common error involves illegible handwriting. It is important to print clearly, as unclear information may lead to delays in processing or complications in communication.

An additional mistake often seen is failing to provide accurate contact information. For instance, individuals may omit their phone number or provide an incorrect email address. This can hinder Planned Parenthood's ability to reach out with important test results or information regarding their services.

Another frequent issue occurs with the selection of communication methods. Some individuals neglect to check the boxes indicating how they wish to be contacted. This oversight can create confusion about how a patient prefers to receive sensitive information, such as test results.

Finally, people sometimes leave out critical medical history details. Information regarding previous pregnancies, menstrual cycles, or current symptoms should be documented thoroughly. Failing to provide this information can affect the quality of care and guidance received.

Documents used along the form

When seeking services at Planned Parenthood, several documents may be required alongside the Planned Parenthood Proof form. These forms ensure that all necessary information is collected and that your rights are upheld throughout the process. Below are some commonly used forms and documents.

Patient’s Bill of Rights and Responsibilities: This document outlines your rights as a patient, detailing the responsibilities of the healthcare provider to respect your privacy and maintain high standards of care.
Patient Complaints Policy: This policy provides procedures for patients to voice any concerns or complaints about their treatment, ensuring a clear path for addressing issues that may arise.
Request for Medical Services: This form helps initiate your request for specific medical services. It also confirms your understanding of the services to be provided, including benefits and risks.
Acknowledgement of Receipt of Notice of Health Information Privacy Practices: This document explains how your health information will be handled and shared, safeguarding your personal data and ensuring confidentiality.
Consent for Treatment: This form confirms your consent for the medical services being provided, including any specific treatments or tests that may be performed during your visit.
Interpreter Services Request: If you require assistance with language interpretation, this form helps you request those necessary services to ensure you understand the information presented during your appointment.

These documents work together to foster an environment of trust and transparency between you and your healthcare provider. Understanding each form can enhance your experience and help you make informed decisions about your health.

Similar forms

Informed Consent Form: This document is similar in that it ensures patients understand the services provided and agree to them. Like the Planned Parenthood Proof Form, it requires signatures to confirm that the patient has received and comprehended the necessary information.
Patient Health History Form: Both documents collect vital personal health information. They aim to assess the patient's medical background to facilitate appropriate care, assisting providers in making informed decisions about treatment or tests.
HIPAA Acknowledgment Form: This form, like the Planned Parenthood Proof Form, emphasizes privacy and confidentiality. It outlines how patient information will be used and protected while ensuring patients understand their rights regarding their health information.
Referral Form: Much like the Proof Form, the referral form is used when further assistance is needed. It documents the patient's consent to transfer their information for specialized care, ensuring continuity of services.
Financial Assistance Application: Both forms require personal details about income and family size. They help assess eligibility for assistance programs, ensuring that patients can access necessary services.
Patient Notification of Rights: Similar to the Proof Form, this document outlines the rights of patients regarding their care. It informs them about their rights to make decisions and express concerns, fostering a transparent healthcare environment.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it’s crucial to approach the task thoughtfully. Below are some key dos and don’ts to ensure the process goes smoothly for you and the staff.

Do: Print your information clearly to avoid any confusion.
Do: Provide accurate contact details so you can be reached easily.
Do: Read all instructions carefully before starting to ensure you understand what is required.
Do: Ask questions if you don't understand any part of the form.
Don’t: Leave any mandatory fields blank; incomplete forms can delay your service.
Don’t: Provide misleading or incorrect information; this can affect your care.

Following these guidelines can help make your experience as positive and productive as possible while ensuring your information is both accurate and respectful of your needs.

Misconceptions

Understanding the Planned Parenthood Proof form is essential for individuals seeking services. However, several misconceptions exist regarding its purpose and use. Here are some of the most common misunderstandings:

Misconception 1: The form is solely for obtaining a pregnancy test.

While the form is primarily associated with pregnancy testing, it is comprehensive and includes various medical screening components. It captures essential patient information that guides the medical services provided.

Misconception 2: My information will not remain confidential.

Many people worry about the privacy of their data. The clinic emphasizes its commitment to confidentiality, promising that personal details are handled securely and shared only as necessary for care.

Misconception 3: This form requires a legal guardian’s signature for all patients.

While a legal guardian’s consent is necessary for minors, adults can sign the form independently. It is crucial to determine the patient’s age and specific circumstances regarding consent.

Misconception 4: I must decide on my medical services immediately after completing the form.

The form allows you to express your preferences, but there is no obligation to make immediate decisions. Patients are encouraged to ask questions and discuss their options with healthcare providers before agreeing to any service.

Key takeaways

Understanding the Planned Parenthood Proof form is essential for those seeking medical services. Here are key takeaways to keep in mind:

The form must be filled out completely and legibly to prevent delays in service.
Confidentiality is a priority. Personal information can only be shared through specified contact methods like phone or mail.
Indicate a method for receiving test results. It's useful to provide a password for results communicated by phone.
Awareness of your medical history is important. Be honest about any previous experiences related to pregnancy or reproduction.
A space is provided to detail the reason for the test, which helps healthcare providers understand your situation.
The form allows you to specify what test results you're hoping for, which can guide the conversation regarding care options.
Seek clarification on any part of the form or the services offered. Staff are available to provide necessary information.
Note that if you require language assistance, inform the staff. They may need to refer you to another provider if necessary.
Participants should understand that they can change their mind about receiving services at any time.

Being informed and prepared can help streamline the process and ensure a supportive experience when using the Planned Parenthood Proof form.

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