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Blank 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 and medical information to ensure that patients receive appropriate care while maintaining their confidentiality. For those interested in utilizing these services, completing the form accurately is an important step; please fill it out by clicking the button below.

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The Planned Parenthood Proof form serves as a vital document for individuals seeking medical services related to pregnancy testing and reproductive health. This comprehensive form collects essential personal information, including the patient's name, contact details, and emergency contact, while ensuring confidentiality is prioritized. Patients are asked to indicate their preferred methods of communication for receiving test results, which may include phone calls or mail. The form also prompts individuals to disclose their medical history, including menstrual cycles and any symptoms they may be experiencing. Furthermore, it inquires about birth control methods and any past experiences that may influence their current situation, such as contraceptive failures or emotional distress related to their reproductive health. Additionally, the form outlines the patient's rights and responsibilities, emphasizing the importance of informed consent and the availability of interpretive services for those who may need assistance understanding the information provided. By completing this form, patients engage in a process that not only respects their autonomy but also facilitates a supportive environment for discussing sensitive health matters.

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 _______________

Frequently Asked Questions

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 for processing medical requests, including personal details, medical history, and preferences for communication regarding test results.
Why do I need to provide my personal information?
Your personal information is necessary for a few reasons. It helps the clinic maintain accurate medical records, ensures that you receive appropriate care, and allows the staff to contact you regarding test results or follow-up appointments. All information is kept confidential, in line with privacy practices.
How will I be contacted regarding my test results?
You can choose how you want to be contacted about your test results. Options include phone calls or mail, and you can specify a password for receiving results over the phone. It's important to select a method that works best for you to ensure you receive timely information.
What should I do if I have questions about the form?
If you have any questions about the form or the information requested, you are encouraged to ask the staff for clarification. They are there to help you understand everything you need to know, ensuring you feel comfortable and informed before proceeding.
What happens if I need an interpreter?
If you require language interpreter services, it is important to inform the staff. While Planned Parenthood strives to provide these services, they may not always be immediately available. In some cases, you might be referred to another facility that can accommodate your needs.
Can I change my mind about receiving services?
Yes, you have the right to change your mind at any time regarding the medical services you wish to receive. It’s important that you feel confident and comfortable with your healthcare choices, and the staff will support you in making the decision that’s best for you.
What if my test results are positive for a sexually transmitted infection?
If your test results indicate a positive result for certain sexually transmitted infections (STIs), the law requires that these results be reported to public health agencies. Planned Parenthood will provide you with referrals for further diagnosis or treatment, ensuring you receive the care you need.

Misconceptions

Misconceptions about the Planned Parenthood Proof form can lead to confusion. Here are seven common misunderstandings:

It is only for women. The form is designed for anyone seeking pregnancy testing or related services, regardless of gender identity.
Providing personal information is optional. While some information may seem optional, accurate details are essential for effective care.
Test results will be communicated via email. Email cannot be used for test results. Other methods, such as phone or mail, are employed for confidentiality.
The form is too complex. While it may seem lengthy, each section is necessary for ensuring proper medical care and understanding patient needs.
All information shared is public. Confidentiality is a priority. Information is protected and only shared as required by law.
Only pregnancy-related issues are addressed. The form also includes questions about sexual health, birth control, and personal safety, allowing for comprehensive care.
Signature means consent for all services. Signing the form indicates understanding of the information provided, not automatic consent for all treatments.

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 fields: Forgetting to complete mandatory sections, such as name or date of birth, can delay your appointment.
Incorrect contact information: Providing wrong phone numbers or email addresses may prevent the clinic from reaching you with important test results.
Not specifying preferred contact method: Failing to check how you want to be contacted can lead to confusion about how you will receive your results.
Overlooking the emergency contact section: Not providing an emergency contact can be problematic in case of urgent situations.
Incomplete medical history: Leaving out relevant medical history, such as previous pregnancies or conditions, can affect your care.
Not indicating the reason for the test: Failing to specify why you are taking the test can lead to inappropriate care or follow-up.
Ignoring the consent section: Not signing or dating the consent form can result in delays or denial of services.
Misunderstanding the privacy practices: Not reading or asking questions about the privacy notice can lead to confusion about how your information will be used.
Failing to ask questions: Not seeking clarification on anything you don’t understand can lead to missed information that is important for your care.

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Document Data

Fact Name	Description
Provider Information	Planned Parenthood of Southeastern Virginia operates at two locations: Hampton (403 Yale Drive) and Virginia Beach (515 Newtown Road).
Contact Numbers	The clinic can be reached at (757) 826-2079 for Hampton and (757) 499-7526 for Virginia Beach.
Confidentiality Commitment	The organization emphasizes the importance of maintaining patient confidentiality throughout the testing process.
Patient's Bill of Rights	Patients receive a copy of the Patient’s Bill of Rights and Responsibilities, ensuring they are informed of their rights.
Medical Screening	The form includes a medical screening section where patients can report their last menstrual period and any current symptoms.
Emergency Contact	Patients are encouraged to provide an emergency contact name and phone number for added safety.
Legal Reporting Requirements	If tests for certain sexually transmitted infections are positive, reporting to public health agencies is mandated by law.
Patient Consent	Patients must consent to the use and disclosure of their health information as outlined in the Notice of Health Information Privacy Practices.
Educational Support	Patients are provided with information about tests, treatments, and contraceptive methods, including potential benefits and risks.

Similar forms

The Medical History Form is similar to the Planned Parenthood Proof form in that both documents collect essential patient information before a medical procedure or test. The Medical History Form typically requires patients to provide details about their previous health conditions, medications, and allergies. This information helps healthcare providers assess potential risks and tailor treatments accordingly. Just like the Planned Parenthood Proof form, it emphasizes the importance of accuracy and completeness in the information provided, ensuring that patients receive the best possible care.

The Consent for Treatment Form shares similarities with the Planned Parenthood Proof form as both require patients to acknowledge their understanding of the services being provided. This document outlines the specific treatments or procedures a patient agrees to undergo and often includes information about potential risks and benefits. Both forms prioritize informed consent, ensuring that patients are aware of what to expect and can make knowledgeable decisions regarding their healthcare.

The Patient Intake Form is another document akin to the Planned Parenthood Proof form. It gathers a range of information, including personal details, medical history, and insurance information. Like the Proof form, the Patient Intake Form is designed to streamline the process of providing care by collecting necessary data upfront. Both documents aim to create a comprehensive profile of the patient to facilitate effective communication and care delivery.

The Release of Information Form resembles the Planned Parenthood Proof form in its focus on patient confidentiality and the handling of sensitive information. This form allows patients to authorize the sharing of their medical records with other healthcare providers or entities. Just as the Proof form ensures that patients understand their rights regarding privacy, the Release of Information Form reinforces the importance of maintaining confidentiality while allowing for necessary communication between providers.

The Authorization for Emergency Treatment Form is similar to the Planned Parenthood Proof form in that it addresses the need for consent in urgent situations. This document allows healthcare providers to act swiftly in emergencies when a patient may not be able to provide consent themselves. Both forms emphasize the importance of patient autonomy while ensuring that care can be delivered effectively when time is of the essence.

The Insurance Information Form shares common ground with the Planned Parenthood Proof form by collecting essential financial information from patients. This document typically asks for insurance details and coverage specifics, which helps healthcare providers understand the financial aspects of the patient's care. Both forms aim to ensure that patients are informed about their options and responsibilities regarding payment for services rendered.

The Patient Bill of Rights is akin to the Planned Parenthood Proof form as both documents underscore the rights and responsibilities of patients within the healthcare system. The Patient Bill of Rights outlines what patients can expect regarding their treatment and care, including the right to privacy and informed consent. Similarly, the Proof form emphasizes the importance of understanding these rights, ensuring patients feel empowered in their healthcare journey.

The Patient Feedback Form is similar to the Planned Parenthood Proof form in that it seeks to gather input from patients about their experiences. This document allows patients to share their thoughts on the care they received, which can help healthcare providers improve their services. Both forms emphasize the importance of patient engagement and communication, highlighting the role of feedback in enhancing the overall quality of care.

The New York Motorcycle Bill of Sale form is an important document used to record the sale and transfer of ownership of a motorcycle. It serves as proof of purchase for both the buyer and the seller. Having this form completed accurately can help prevent disputes and ensure a smooth transaction. For those looking to access this form easily, it can be found at documentonline.org/blank-new-york-motorcycle-bill-of-sale/.

The Financial Agreement Form resembles the Planned Parenthood Proof form by outlining the financial responsibilities of patients before receiving services. This document typically details payment plans, co-pays, and any financial assistance options available. Like the Proof form, it aims to ensure that patients are fully informed about the costs associated with their care, fostering transparency in the healthcare process.

The Follow-Up Care Plan is similar to the Planned Parenthood Proof form in that it provides patients with essential information about their ongoing care after a visit or procedure. This document outlines any recommended follow-up appointments, tests, or treatments. Both forms aim to empower patients by keeping them informed and involved in their healthcare decisions, ensuring they understand the next steps in their care journey.