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 related to pregnancy testing. This form ensures that patients are informed about their rights, responsibilities, and the confidentiality of their health information. By completing this form, individuals can receive the necessary evaluations and treatments in a supportive and confidential environment.
The Planned Parenthood Proof form is an essential document designed to facilitate the medical services offered by Planned Parenthood of Southeastern Virginia. This form collects vital information from patients, including personal details like name, address, and contact information, ensuring that the clinic can maintain effective communication while respecting patient confidentiality. It also includes sections for medical screening, allowing patients to disclose their health history, reasons for seeking a pregnancy test, and any current symptoms. Additionally, the form addresses important topics such as birth control usage and any history of reproductive health issues. Patients are prompted to provide their preferences for communication regarding test results, emphasizing the clinic's commitment to confidentiality and patient autonomy. The form concludes with an acknowledgment of health information privacy practices, ensuring that patients understand their rights and the nature of the services they will receive. Overall, the Planned Parenthood Proof form is designed to gather necessary information while fostering a supportive environment for patients seeking reproductive health services.
What is the 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, particularly for urine pregnancy tests. It ensures that the clinic can provide the best possible care while maintaining confidentiality and adhering to patient rights.
Why do I need to fill out this form?
Filling out the form helps the clinic understand your medical history, reasons for the visit, and personal information that is necessary for your care. This information allows the staff to provide tailored support and address any specific health needs you may have.
How is my information kept confidential?
Your confidentiality is a top priority. The clinic will use your information only for healthcare purposes and will not share it without your consent. Communication regarding your results or health information will be conducted through secure methods, such as phone calls or mail in plain envelopes.
What should I do if I have questions while filling out the form?
If you have any questions while completing the form, you can ask the clinic staff for assistance. They are there to help you understand the information and ensure that you feel comfortable throughout the process.
What happens if I need language interpreter services?
If you require language interpreter services, it is important to inform the staff before you give consent. While free services may not always be immediately available, the clinic will do its best to accommodate your needs, possibly by referring you to another facility if necessary.
Can I change my mind about receiving services?
Yes, you have the right to change your mind at any time about receiving medical services at Planned Parenthood. Your comfort and choice are important, and you should feel empowered to make decisions about your healthcare.
What if I have a history of certain medical conditions?
If you have a history of specific medical conditions, such as abnormal bleeding or ectopic pregnancy, it is crucial to disclose this information on the form. This will help the clinic staff provide the appropriate care and support based on your medical history.
What are the potential outcomes of the pregnancy test?
The urine pregnancy test can yield either a negative or positive result. Depending on the outcome, the clinic will provide information about next steps, including options for further testing or support services.
How will I receive my test results?
You will have the opportunity to choose how you want to receive your test results. Options include phone calls or mail. If you prefer to receive results over the phone, you will need to provide a password for security purposes.
What should I do if I experience problems related to my pregnancy or birth control?
If you are experiencing any problems related to pregnancy or birth control, it is important to discuss these issues with the clinic staff. They are available to provide support, answer your questions, and help you navigate your options.
Filling out the Planned Parenthood Proof form correctly is essential for a smooth experience. Here are some key takeaways:
This form is designed for anyone seeking pregnancy testing, regardless of gender identity. It includes options for transgender individuals and encourages the use of preferred pronouns.
Planned Parenthood is committed to maintaining patient confidentiality. The form explicitly states that personal information will be kept private, and contact methods are chosen by the patient.
The form encourages patients to ask questions if they do not understand something. Staff members are available to clarify any concerns.
Filling out the form does not obligate anyone to take a test. Patients can choose whether or not to proceed with the services offered.
Patients have the right to change their minds about receiving services at any time, even after signing the form.
While some services may be offered at low or no cost, patients may still be responsible for certain tests or referrals that require payment.
The form is for individuals who may suspect they are pregnant or are experiencing related issues, not just for confirmed pregnancies.
Email is not a requirement for receiving test results. Patients can choose how they want to be contacted, including by phone or mail.
Planned Parenthood staff includes licensed professionals. Additionally, the facility is a teaching institution, meaning trainees work under strict supervision to ensure quality care.
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 _____________________________________________________
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Illegible handwriting: Many individuals fail to print legibly. This can lead to misunderstandings or errors in processing the information. Ensure that all sections are filled out clearly.
Incomplete information: Some people leave sections blank. For example, omitting the emergency contact name or phone number can create issues in case of an emergency. Fill out every required field to avoid delays.
Incorrect contact method selection: It's common for applicants to choose contact methods that are not suitable for their situation. For instance, selecting email for test results when it is stated that email cannot be used can lead to confusion. Review the options carefully.
Not providing a password: When receiving test results via phone, a password is necessary. Failing to provide this can prevent staff from sharing important information. Make sure to include a password in the designated space.
When filling out the Planned Parenthood Proof form, keep these important tips in mind:
The Patient Information Form is similar to the Planned Parenthood Proof form in that both documents collect essential personal and medical information from patients. This form typically requires details such as the patient's name, contact information, and medical history. It serves to establish a baseline for the healthcare provider to understand the patient's needs and concerns. Just as the Planned Parenthood Proof form emphasizes confidentiality and informed consent, the Patient Information Form also includes sections where patients acknowledge their understanding of privacy practices and their rights regarding medical treatment.
The Medical History Questionnaire shares similarities with the Planned Parenthood Proof form by gathering detailed health information from patients. This document often includes questions about past medical conditions, surgeries, and family health history. It helps healthcare providers assess risk factors and tailor treatments accordingly. Like the Planned Parenthood form, the Medical History Questionnaire prioritizes patient confidentiality and requires patients to provide accurate information to ensure effective care.
The Consent for Treatment form is another document akin to the Planned Parenthood Proof form. It typically outlines the procedures or treatments a patient agrees to undergo and includes information about potential risks and benefits. Patients must sign this form to indicate their understanding and acceptance of the treatment plan. This process mirrors the Planned Parenthood form's focus on informed consent, ensuring that patients are fully aware of their healthcare choices before proceeding.
The Release of Information form is similar in function to the Planned Parenthood Proof form, as it allows patients to authorize the sharing of their medical records with other healthcare providers or institutions. This document is crucial for continuity of care, as it ensures that all relevant parties have access to the patient's medical history. Like the Planned Parenthood form, it emphasizes the importance of patient consent and confidentiality in handling sensitive health information.
The Insurance Information form shares a common purpose with the Planned Parenthood Proof form by collecting necessary details to facilitate billing and insurance claims. Patients provide their insurance provider's information, policy numbers, and coverage details. This form is essential for ensuring that patients receive the appropriate financial support for their medical services. Similar to the Planned Parenthood form, it requires patients to verify the accuracy of the information they provide.
The Texas Boat Bill of Sale form is similar in nature to various important documents used in personal transactions, as it serves as proof of the sale and transfer of ownership of a boat in Texas. This form not only outlines key details about the transaction such as the buyer and seller's information but also includes the boat's specifications and sale price. For those involved in the buying or selling process, it's crucial to understand this form fully, much like familiarizing oneself with other important documents, including the Vessel Bill of Sale, ensuring a smooth and legally binding transfer of ownership.
The Patient Rights and Responsibilities document is akin to the Planned Parenthood Proof form in that it outlines the rights of patients and their responsibilities within the healthcare setting. This document typically informs patients of their rights to privacy, informed consent, and respectful treatment. Just as the Planned Parenthood form emphasizes the importance of understanding one's rights, the Patient Rights and Responsibilities document ensures that patients are aware of the standards of care they can expect.
Finally, the Health History Form is comparable to the Planned Parenthood Proof form as it seeks to compile a comprehensive overview of a patient's health background. This document often includes questions about allergies, medications, and previous illnesses. It assists healthcare providers in making informed decisions about treatment options. Like the Planned Parenthood form, the Health History Form reinforces the need for accurate information to ensure patient safety and effective care.