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Fill Out a Valid Planned Parenthood Proof Template

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 patient rights are upheld and that confidentiality is maintained throughout the healthcare process. To begin your journey, fill out the form by clicking the button below.

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Content Overview

Guide to Writing Planned Parenthood Proof

Completing the Planned Parenthood Proof form is an important step in accessing medical services. This form collects essential information about you and your medical history, ensuring that your healthcare provider can offer the best possible care. Follow the steps below to fill out the form accurately.

Print Legibly: Use clear, legible handwriting to fill out the form. This ensures that all information is easily readable.
Check the Box: Indicate that you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy by checking the appropriate box.
Provide Personal Information: Fill in your last name, first name, middle initial, address, apartment number (if applicable), city, state, and zip code.
Employment Details: Include your employer's name and your email address. Note that the email cannot be used for test results.
Contact Information: Enter your home phone number, cell phone number, and work phone number.
Emergency Contact: Provide the name and phone number of an emergency contact.
Preferred Contact Method: Check the methods you prefer for receiving contact from the clinic, such as phone call or mail.
Set a Password: Create a password to receive test results over the phone.
Demographic Information: Fill in your date of birth, sex, monthly income, family size, and preferred pronoun.
Living Will: Indicate if you have a living will by checking "Yes" or "No."
Source of Referral: Select how you heard about Planned Parenthood from the provided options.
Race and Ethnicity: Choose your race and indicate if you are Hispanic.
Education Level: Mark the highest level of education you have completed.
Medical Screening: Answer questions regarding your last menstrual period, current symptoms, and history of pregnancy or birth control issues.
Assessment Section: This part is to be completed by clinic staff, so you will not need to fill this out.
Consent Section: Read the information carefully and sign where indicated to acknowledge your understanding and consent.

Once you have completed the form, review it for accuracy before submitting it to the clinic. The staff will use this information to assist you with your medical needs effectively.

Document Breakdown

Fact Name	Description
Organization	The form is from Planned Parenthood of Southeastern Virginia.
Location	Addresses include 403 Yale Drive, Hampton, VA 23666, and 515 Newtown Road, Virginia Beach, VA 23462.
Contact Information	Phone numbers are (757) 826-2079 and (757) 499-7526.
Patient's Bill of Rights	Patients must acknowledge receipt of the Patient’s Bill of Rights and Responsibilities.
Confidentiality Commitment	Planned Parenthood is committed to maintaining patient confidentiality.
Communication Preferences	Patients can choose how they wish to be contacted regarding test results.
Income Disclosure	Patients are asked to provide their monthly income and family size.
Medical History	The form includes sections for medical screening and history relevant to pregnancy tests.
Legal Compliance	Reporting positive STI tests to public health agencies is required by Virginia law.

FAQ

What is the Planned Parenthood Proof form used for?

The Planned Parenthood Proof form is primarily used to gather essential information from patients seeking medical services, particularly for pregnancy testing. It helps ensure that the clinic can provide appropriate care by collecting personal details, medical history, and preferences for communication. This form is a crucial step in the process, as it allows healthcare providers to understand the patient's needs and circumstances better.

How is my confidentiality protected when I fill out this form?

Your confidentiality is a top priority at Planned Parenthood. The information you provide on the Proof form is kept private and secure. The clinic will only contact you through the methods you select, such as phone or mail, and will use plain envelopes for sensitive communications. Additionally, the staff is trained to handle your information with care, ensuring that it is only shared with those who need to know for your care.

What should I do if I have questions about the form or my health?

If you have any questions about the form or your health, don’t hesitate to ask the clinic staff. They are there to help you understand the information and the services available. You can inquire about any part of the form, the tests being conducted, or any health concerns you may have. Remember, it's important to feel comfortable and informed about your healthcare choices.

Can I change my mind about receiving services after filling out the form?

Yes, you have the right to change your mind at any point about receiving medical services. The form is not a binding contract; it simply indicates your request for services. If you decide not to proceed, you can inform the staff, and they will respect your decision. Your autonomy in healthcare decisions is essential, and you should feel empowered to make choices that are right for you.

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Planned Parenthood Proof 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 _______________