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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, including pregnancy testing. This form ensures that patients are informed about their rights, the services provided, and the importance of confidentiality in their healthcare. By completing this form, individuals can help facilitate a smooth and supportive experience during their visit.

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The Planned Parenthood Proof form is a crucial document designed to streamline the process for individuals seeking medical services related to pregnancy testing and reproductive health. This form collects essential personal information, including contact details, employment status, and medical history, ensuring that healthcare providers can offer tailored support. Patients are asked to indicate their preferred methods of communication for receiving test results, emphasizing the organization’s commitment to confidentiality. The form also includes sections for medical screening, where clients report their last menstrual period and any symptoms they may be experiencing. Furthermore, it addresses sensitive topics such as birth control usage and any history of reproductive coercion, allowing for a comprehensive assessment of the patient's needs. By gathering this information, Planned Parenthood aims to provide informed care while respecting the privacy and autonomy of each individual.

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Common Questions

What is the Planned Parenthood Proof form?

The Planned Parenthood Proof form is a document used by Planned Parenthood of Southeastern Virginia to collect essential information from patients seeking medical services, particularly for urine pregnancy tests. It ensures that the clinic has accurate details to provide appropriate care while maintaining patient confidentiality.

What information do I need to provide on the form?

You will need to fill out personal details such as your name, address, contact information, and date of birth. Additionally, you must provide information regarding your medical history, reason for the test, and any current symptoms. This information helps the clinic staff assess your situation accurately.

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

Planned Parenthood is committed to maintaining your confidentiality. The form includes a section where you can choose how you prefer to be contacted regarding your test results. Options include phone calls or mail, and any communication will be handled discreetly, often in a plain envelope.

Can I receive my test results over the phone?

Yes, you can receive your test results over the phone. To do so, you must provide a password on the form. This password ensures that only you can access your results, adding an extra layer of security to your personal health information.

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

If you have any questions about the form or the services offered, you are encouraged to ask the clinic staff for clarification. They are available to help you understand the information and ensure you feel comfortable with the process.

What happens if I need an interpreter to understand the information?

If you require language interpreter services, you should inform the staff. While these services may not always be immediately available, the clinic will make efforts to accommodate your needs. In some cases, they may refer you to another healthcare facility that can provide the necessary interpretation services.

What if I change my mind about receiving services?

You have the right to change your mind about receiving medical services at any time. If you decide not to proceed with the services after filling out the form, simply communicate your decision to the clinic staff. They will respect your choice without any pressure.

What does it mean if my test results are positive?

If your test results are positive, the clinic will provide you with information about your options moving forward. This may include referrals for further testing, treatment, or counseling, depending on your needs. The staff is there to support you through this process and answer any questions you may have.

Preview - Planned Parenthood Proof Form

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 _______________

Similar forms

Patient Registration Form: Similar to the Planned Parenthood Proof form, this document collects essential personal information from patients, including contact details, medical history, and insurance information. Both forms prioritize patient confidentiality and ensure that the information provided is accurate and complete.
Informed Consent Form: Like the Planned Parenthood Proof form, this document ensures that patients understand the procedures and treatments they will undergo. It emphasizes the importance of informed decision-making and the right to ask questions before consenting to care.
Quitclaim Deed Form – This essential document facilitates the transfer of property ownership in Ohio without warranties, allowing the grantor to relinquish their interest. For more information on how to complete this form correctly, visit Ohio PDF Forms.
HIPAA Acknowledgment Form: This form, similar to the Planned Parenthood Proof form, outlines the patient's rights regarding their health information. It details how personal health information will be used and shared, reinforcing the commitment to confidentiality.
Medical History Questionnaire: This document gathers comprehensive information about a patient’s past medical history, akin to the medical screening section of the Planned Parenthood Proof form. Both forms help healthcare providers assess the patient's health and provide appropriate care.
Insurance Information Form: This form collects details about a patient’s insurance coverage, much like the Planned Parenthood Proof form collects personal and financial information. Both forms aim to facilitate billing and ensure that patients understand their financial responsibilities.
Appointment Confirmation Form: Similar in purpose, this document confirms the details of a patient's upcoming appointment. Both forms serve to ensure that patients are aware of their scheduled services and any necessary preparations.
Referral Form: This document is used to refer patients to specialists, mirroring the Planned Parenthood Proof form's emphasis on the importance of follow-up care. Both forms ensure that patients receive comprehensive support throughout their healthcare journey.
Release of Information Form: Like the Planned Parenthood Proof form, this document allows patients to authorize the sharing of their health information with other providers. Both forms highlight the patient's control over their medical records and who has access to them.
Emergency Contact Form: This form collects information about a patient’s emergency contacts, similar to the Planned Parenthood Proof form. Both documents ensure that healthcare providers can reach someone on the patient's behalf in case of an emergency.

Misconceptions

Misconceptions about the Planned Parenthood Proof form can lead to confusion and misinformation. Here are seven common misconceptions, along with clarifications for each:

The form is only for women. Many believe that the form is exclusively for women, but it is designed for anyone seeking reproductive health services, including transgender individuals.
Providing an email address is mandatory. Some think that they must provide an email address, but it is only optional and cannot be used for test results.
The information is not confidential. A common misconception is that personal information is not kept confidential. In reality, Planned Parenthood is committed to maintaining patient confidentiality and follows strict privacy practices.
All services are free. Many assume that all services provided are free of charge. While some services may be offered at no cost, others may require payment or insurance coverage.
Test results will be communicated via email. Some individuals believe they will receive test results through email. However, results are typically communicated through phone calls, mail, or in-person visits to ensure confidentiality.
The form is only for pregnancy testing. Many think the form is solely for pregnancy tests, but it also includes medical screening for various reproductive health concerns.
Patients cannot ask questions about the form. It is a misconception that patients should not ask questions. In fact, patients are encouraged to seek clarification on any part of the form or the services provided.

Understanding these misconceptions can help individuals feel more informed and comfortable when seeking services at Planned Parenthood.

File Attributes

Fact Name	Description
Provider Information	The form is from Planned Parenthood of Southeastern Virginia, with locations in Hampton and Virginia Beach.
Patient’s Bill of Rights	Patients must acknowledge receipt of the Patient’s Bill of Rights and Responsibilities and the Patient Complaints policy.
Confidentiality Assurance	The organization commits to maintaining patient confidentiality, detailing methods of contact for test results.
Medical Screening	The form includes a medical screening section where clients report symptoms and medical history relevant to pregnancy testing.
Consent for Services	Patients must consent to the use and disclosure of their health information as outlined in the Notice of Health Information Privacy Practices.
Legal Requirements	In Virginia, certain positive test results for sexually transmitted infections must be reported to public health agencies as mandated by law.