The Planned Parenthood Proof form is a document used to gather essential information from patients seeking medical services, particularly urine pregnancy tests. This form ensures that patients understand their rights and responsibilities while maintaining confidentiality throughout the process. If you need to fill out this form, please click the button below.
When filling out the Planned Parenthood Proof form, there are several important points to keep in mind:
Taking the time to complete the form accurately and thoughtfully will help ensure you receive the best possible care.
When seeking medical services at Planned Parenthood, several forms and documents may accompany the Planned Parenthood Proof form. Each of these documents serves a specific purpose in ensuring that patients receive the care they need while protecting their rights and privacy.
Each of these documents plays a vital role in the healthcare process at Planned Parenthood. They help ensure that patients are informed, their rights are protected, and that the care they receive is appropriate and personalized.
Patient Intake Form: Similar to the Planned Parenthood Proof form, this document collects personal information from patients, including contact details, medical history, and insurance information, ensuring that healthcare providers have the necessary data to offer appropriate care.
Consent for Treatment Form: This document outlines the patient's consent to receive medical services. Like the Planned Parenthood form, it emphasizes the importance of understanding the treatment options and potential risks involved.
Privacy Practices Acknowledgment: Both forms require patients to acknowledge their understanding of privacy practices related to their health information, ensuring compliance with regulations and maintaining confidentiality.
Medical History Questionnaire: This document gathers detailed medical history from patients. It serves a similar purpose as the Planned Parenthood Proof form, helping providers assess any pre-existing conditions that may affect care.
Emergency Contact Form: Similar in nature, this document requests emergency contact information, ensuring that healthcare providers can reach a designated person in case of an emergency.
Operating Agreement Form: Important for LLCs, this document details the operations and relationships among members, similar to the operational structure outlined at arizonapdf.com.
Insurance Information Form: This document collects details about the patient's insurance coverage. Like the Planned Parenthood form, it is crucial for billing purposes and ensures that patients receive the benefits they are entitled to.
Release of Information Form: This form allows patients to authorize the sharing of their health information with third parties. It parallels the Planned Parenthood Proof form in terms of ensuring informed consent regarding the use of personal health data.
Patient Satisfaction Survey: Similar to the Planned Parenthood form, this document seeks feedback from patients about their experience, helping healthcare providers improve services and address any concerns.
Referral Form: This document is used when a patient is referred to another healthcare provider. Like the Planned Parenthood Proof form, it ensures that all necessary patient information is transferred for continuity of care.
Follow-Up Appointment Request: This form is used to schedule follow-up visits. It shares similarities with the Planned Parenthood Proof form by collecting patient information necessary for future care and treatment planning.
Texas Temporary Tag - Use of the Texas Temporary Tag form helps maintain accurate vehicle registration statistics.
For businesses operating in New York, understanding the implications of a well-drafted Non-compete Agreement is crucial to ensure they can protect their competitive edge. This document serves to delineate the boundaries within which former employees can operate, safeguarding valuable business interests.
Dekalb County Water New Service Application - Employees will use this form to process your water service application.
How to Buy Melaleuca Without Membership - Your request will not be processed if received after the 25th of the month.
Illegible Writing: One of the most common mistakes occurs when individuals do not print their information clearly. If the handwriting is difficult to read, it may lead to misunderstandings or errors in processing the form.
Incomplete Information: Failing to fill out all required fields can delay the process. Each section, from personal details to medical history, is essential for ensuring proper care and communication.
Incorrect Contact Preferences: People sometimes check the wrong boxes when indicating how they prefer to be contacted. This can result in missed communications, particularly if important test results need to be shared.
Misunderstanding Consent: Some individuals may not fully grasp the implications of the consent section. It's crucial to read and understand what is being agreed to, as this affects privacy and the sharing of health information.
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
TV
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
No
Are you currently experiencing?
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?
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
For NEGATIVE Results-
V=Verbal H=Handout
CIIC EC
CIIC Pregnancy Tests
Explained limitations of test (morning urine
CIIC HOPE
STIs
sample/time since last period)
Advised re-test in 1-2 weeks
BCM Options
CIIC Contraceptive Implant
Prenatal Care
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:
Revised March 2014
Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices I-B-2a Revised June 2012
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 _____________________________________________________