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Fill Your Planned Parenthood Proof Form

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to gather essential information from patients seeking medical services, particularly related to pregnancy testing. This form ensures that patients understand their rights and responsibilities while also maintaining confidentiality throughout the process. Completing the form accurately is crucial for receiving timely and appropriate care.

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The Planned Parenthood Proof form serves as an essential document for individuals seeking medical services related to reproductive health. This form is designed to gather vital information from patients, ensuring that their medical needs are met effectively while also safeguarding their privacy. It includes sections for personal details, such as name, address, and contact information, allowing the clinic to maintain communication regarding test results and follow-up care. Patients are asked to indicate their preferred methods of contact, ensuring that they receive information in a manner that suits them best. Additionally, the form addresses medical history and current health concerns, including questions about pregnancy symptoms and birth control usage. The inclusion of a medical screening section allows clinic staff to assess the patient's situation more thoroughly. Furthermore, the form emphasizes the importance of informed consent, detailing the patient's rights and responsibilities, as well as the clinic's commitment to confidentiality. By signing this document, patients acknowledge their understanding of the services provided, the potential risks and benefits, and their right to ask questions, thus fostering an environment of transparency and trust.

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 _______________

Common mistakes

Illegible handwriting: Filling out the form in a way that is hard to read can lead to misunderstandings or errors in processing.
Missing required information: Not providing all the necessary details, such as last name or date of birth, can delay services.
Incorrect contact preferences: Failing to clearly indicate how you prefer to be contacted may result in missed communications about test results.
Not checking for accuracy: Skipping a review of the completed form can lead to mistakes that affect your care.
Omitting emergency contact information: Not providing an emergency contact can complicate situations where immediate assistance is needed.
Inaccurate income reporting: Providing incorrect income information can impact eligibility for certain services or programs.
Ignoring the medical screening section: Failing to answer questions about your health history can result in inadequate care or testing.
Not specifying preferred pronouns: Leaving out pronouns can lead to discomfort or miscommunication during your visit.
Neglecting to ask questions: Not seeking clarification on any part of the form can lead to confusion and potential issues with care.

↓ PDF File

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Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is important to follow certain guidelines to ensure accuracy and clarity. Below is a list of things you should and shouldn't do:

Do print your information clearly and legibly to avoid any misunderstandings.
Don't use abbreviations or shorthand that may confuse the staff.
Do provide complete and accurate information regarding your medical history and current situation.
Don't leave any required fields blank; this may delay your services.
Do check the methods of contact you are comfortable with for receiving results.
Don't forget to provide a password if you wish to receive test results over the phone.
Do ask questions if you do not understand any part of the form or the services provided.

Misconceptions

Misconceptions about the Planned Parenthood Proof form can lead to misunderstandings regarding its purpose and use. Here are six common misconceptions:

The form is only for women. Many believe that the Planned Parenthood Proof form is exclusively for women. In reality, it is designed for anyone seeking reproductive health services, including transgender individuals.
Providing personal information is optional. Some people think they can skip filling out personal information. However, accurate and complete information is essential for effective medical care and treatment.
The form guarantees a specific outcome. There is a misconception that completing the form will guarantee a positive or negative pregnancy test result. The form does not influence test outcomes; it simply facilitates the testing process.
Confidentiality is not maintained. Many individuals worry that their information will not be kept confidential. Planned Parenthood is committed to maintaining confidentiality as outlined in their privacy practices.
It is not necessary to ask questions. Some people assume they should understand everything without asking for clarification. In fact, the form encourages patients to ask questions if they do not understand any part of the process.
The form is only for emergency situations. There is a belief that the form is only relevant during emergencies. However, it is used for a variety of reproductive health services, including routine screenings and consultations.

Detailed Guide for Using Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is an important step in accessing the healthcare services you need. This form collects essential information to ensure your care is tailored to your individual circumstances. Take your time to complete it accurately, as the information provided will help the staff assist you effectively.

Begin by printing the form legibly. Use a black or blue pen for clarity.
Check the box for the Urine Pregnancy Test to indicate the purpose of the form.
Provide your last name, first name, and middle initial in the designated spaces.
Fill in your address, including apartment number, city, state, and zip code.
List your employer, email address (note that it cannot be used for test results), and phone numbers (home, cell, and work).
Enter the name and phone number of an emergency contact.
Choose how you would like to be contacted regarding your test results (phone call or mail) and provide a password for phone results.
Fill in your date of birth and select your sex.
Indicate your monthly income and family size.
Choose a pronoun you prefer to use.
Answer whether you have a living will.
Indicate how you heard about Planned Parenthood.
Mark your race and ethnicity as applicable.
Indicate your highest level of education completed.
Provide the date of your last menstrual period and specify if it was normal.
Select the reason for your test from the options provided.
Check the results you hope to see (negative, positive, or doesn’t matter).
Answer questions about any current symptoms or birth control methods you are using.
Indicate if you have a history of any relevant medical conditions.
Complete the assessment section if required, which may be filled out by clinic staff.
Sign and date the form, ensuring you acknowledge receipt of the Notice of Health Information Privacy Practices.
If necessary, have a guardian or relative sign the form and provide their relationship to you.