Planned Parenthood Proof Form PDF Details

Planned Parenthood Proof Form is a document used to provide information on an individual's visit to a Planned Parenthood clinic. The form includes details such as the patient's name, date of visit, and health care provider. The purpose of the form is to provide a record of care for both the patient and the clinic.

We have collected some statistical information regarding the planned parenthood proof form. You may learn its length, the typical time required to fill out the form, the fields you'll have to fill in, etc.

QuestionAnswer
Form NamePlanned Parenthood Proof Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespregnancy paperwork, real pregnancy papers, positive pregnancy test papers doctor, planned parenthood pregnancy form

Form Preview 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

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?

 

Yes

No

 

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

No

 

 

Yes

No

 

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)

 

 

 

 

 

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:

 

 

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 _______________

How to Edit Planned Parenthood Proof Form Online for Free

This PDF editor enables you to prepare forms. You don't need to undertake much to modify planned parenthood pregnancy form forms. Just adhere to all of these actions.

Step 1: The first task will be to click on the orange "Get Form Now" button.

Step 2: Now you are on the file editing page. You may change and add text to the form, highlight words and phrases, cross or check particular words, insert images, sign it, erase unnecessary fields, or eliminate them altogether.

You need to enter the following data in order to create the file:

real pregnancy papers fields to fill out

Type in the requested details in the field Test Results You Hope To See, Yes, No Are you currently experiencing, Yes, Are you currently using birth, Do you have a history of Abnormal, SpottingBleeding Fever Abdominal, Yes, No Would you like to discuss, Yes, ASSESSMENT COMPLETED BY CLINIC, Gravida Para Live Births, Urine highsensitivity HCG, Patient Education VVerbal HHandout, and CIIC EC.

real pregnancy papers Test Results You Hope To See, Yes, No Are you currently experiencing, Yes, Are you currently using birth, Do you have a history of Abnormal, SpottingBleeding Fever Abdominal, Yes, No Would you like to discuss, Yes, ASSESSMENT COMPLETED BY CLINIC, Gravida Para Live Births, Urine highsensitivity HCG, Patient Education VVerbal HHandout, and CIIC EC blanks to fill

You have to provide certain particulars inside the box CIIC DMPA CIIC POPs, CIIC Barriers condoms CIIC Essure, Abortion CI Sx of Early Pregnancy, Explained limitations of test, Intake Staff Signature Date, Licensed Qualified Staff Signature, and Revised March.

Filling in real pregnancy papers step 3

The REQUEST FOR MEDICAL SERVICES AND, DATE, Patient Label, Before you give your consent be, I understand that I must tell the, I understand that the information, I will be given information about, Please note that Planned, No guarantee has been given to me, I understand that if tests for, I will be given referrals for, I understand that confidentiality, and I hereby request that a person box is the place to include the rights and responsibilities of all parties.

Finishing real pregnancy papers stage 4

End by reviewing these fields and writing the required information: I hereby acknowledge receipt of, Signature of patient Date, I witness the fact that the, Signature of witness Date, CHECK HERE IF PATIENTS GUARDIAN OR, Signature of any other person, Relationship to patient, Date, I witness the fact that the, and Signature of witness.

Filling out real pregnancy papers part 5

Step 3: Once you have hit the Done button, your form should be available for upload to each electronic device or email address you identify.

Step 4: It can be simpler to create copies of your file. There is no doubt that we will not disclose or view your information.

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