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Fill in a Valid Planned Parenthood Proof Form

The Planned Parenthood Proof form serves as a critical document for patients seeking medical services related to pregnancy testing and reproductive health. This form collects essential personal information and medical history, ensuring that individuals receive the appropriate care while maintaining their confidentiality. By signing the form, patients acknowledge their understanding of the services provided and their rights within the healthcare system.

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Fill in a Valid Planned Parenthood Proof Form

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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 _______________

Document Information

Fact Name	Details
Provider Name	Planned Parenthood of Southeastern Virginia
Location	403 Yale Drive, Hampton, VA 23666 and 515 Newtown Road, Virginia Beach, VA 23462
Contact Numbers	(757) 826-2079 and (757) 499-7526
Patient's Bill of Rights	Patients receive a copy of their rights and responsibilities.
Confidentiality Commitment	The clinic is dedicated to maintaining patient confidentiality.
Medical Screening	Includes questions about the last menstrual period and current symptoms.
Assessment by Clinic Staff	Staff completes an assessment including gravidity and pregnancy test results.
Legal Reporting Requirements	Positive test results for STIs must be reported to public health agencies.
Patient's Consent	Patients must provide informed consent for services and understand their rights.

Planned Parenthood Proof - Usage Guidelines

Completing the Planned Parenthood Proof form is a straightforward process. Follow these steps carefully to ensure that all necessary information is accurately provided. This will help facilitate your visit and ensure that your privacy is maintained.

Print Legibly: Use a pen and write clearly throughout the form.
Check the Box: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy.
Fill in Personal Information: Provide your last name, first name, and middle initial. Include your address, apartment number (if applicable), city, state, and zip code.
Employer and Contact Details: List your employer, email address, home phone number, cell phone number, and work phone number.
Emergency Contact: Write down the name and phone number of an emergency contact.
Contact Methods: Check the methods by which you prefer to be contacted regarding test results (phone call or mail). Provide a password for receiving test results over the phone.
Demographic Information: Fill in your date of birth, sex, monthly income, family size, and preferred pronoun.
Living Will: Indicate whether you have a living will (yes or no).
Referral Source: Select how you heard about Planned Parenthood from the provided options.
Race and Ethnicity: Check the appropriate boxes for your race and ethnicity, and indicate if you are Hispanic.
Education Level: Mark the highest level of education you have completed.
Medical Screening: Complete the section about your last menstrual period, reason for the test, and any symptoms you may be experiencing.
Assessment Section: Leave this section blank; it will be completed by clinic staff.
Signature: Sign and date the form where indicated. If a guardian or relative is signing, they should also provide their relationship to you and sign.

After filling out the form, submit it to the clinic staff. They will review your information and proceed with the necessary evaluations and tests. Your confidentiality will be respected throughout the process.

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Dos and Don'ts

When filling out the Planned Parenthood Proof form, it is essential to be thorough and accurate. Here are ten things to keep in mind:

Do print your information clearly. Legibility is crucial for processing your form.
Do provide accurate contact information. This ensures you can receive important updates.
Do check the preferred method of contact. Indicate how you would like to be reached.
Do be honest about your medical history. This information helps in providing the best care.
Do ask questions if you do not understand something. Clarity is vital for your health decisions.

Don't leave any sections blank. Incomplete forms may delay your service.
Don't use an email address for test results. The form specifies this cannot be used for that purpose.
Don't provide false information. This could impact your treatment and care.
Don't hesitate to discuss sensitive issues. Your comfort and safety are important.
Don't forget to sign and date the form. An unsigned form may not be accepted.

Common mistakes

Illegible handwriting: Many individuals rush through the form, resulting in unclear writing. This can lead to misunderstandings or delays in processing.
Incomplete personal information: Omitting details such as last name, address, or contact numbers can hinder communication and follow-up.
Ignoring the consent section: Failing to read and sign the consent section may lead to confusion about the services provided and the rights of the patient.
Not specifying contact preferences: Not checking how they wish to be contacted can complicate the process of receiving important test results.
Providing inaccurate income information: Misreporting income can affect eligibility for services and support.
Overlooking emergency contact details: Forgetting to include an emergency contact can be problematic in urgent situations.
Neglecting to answer medical history questions: Skipping questions about past medical issues can lead to inadequate care or testing.
Failing to indicate preferred pronouns: Not specifying pronouns can lead to discomfort and misunderstanding during interactions with staff.
Not providing a password for test results: Omitting this detail can delay the retrieval of sensitive information.
Ignoring the 'How did you hear about us?' section: This information helps the clinic improve outreach efforts, yet many leave it blank.

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