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The Planned Parenthood Proof form is a crucial document used by patients seeking medical services related to pregnancy testing and reproductive health. This form collects essential information, ensuring that individuals receive appropriate care while maintaining their privacy and confidentiality. To get started, fill out the form by clicking the button below.

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When seeking medical services, particularly in the realm of reproductive health, understanding the documentation involved is crucial. The Planned Parenthood Proof form serves as an essential tool for patients at Planned Parenthood of Southeastern Virginia, ensuring that individuals receive the necessary care while maintaining their rights and confidentiality. This form encompasses a variety of important sections, including personal information, medical history, and preferences for communication. Patients are asked to provide details such as their name, contact information, and emergency contacts, alongside vital medical screening questions that help clinicians assess their needs effectively. Additionally, the form includes a Patient's Bill of Rights and Responsibilities, reinforcing the commitment to patient care and confidentiality. Understanding the implications of this form can empower individuals to take charge of their health decisions, fostering a supportive environment for discussing sensitive issues related to pregnancy and reproductive health.

Sample - 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 _______________

Document Breakdown

Fact Name	Description
Organization	This form is used by Planned Parenthood of Southeastern Virginia, located at 403 Yale Drive, Hampton, VA, and 515 Newtown Road, Virginia Beach, VA.
Purpose	The form is primarily for patients seeking a urine pregnancy test and outlines the necessary patient information for the procedure.
Patient Confidentiality	Planned Parenthood is committed to maintaining patient confidentiality and provides options for how patients can be contacted regarding test results.
Patient's Bill of Rights	Patients must acknowledge receipt of the Patient’s Bill of Rights and Responsibilities and the Patient Complaints policy before consenting to services.
Governing Law	This form is governed by Virginia state laws regarding health information privacy and patient rights.
Language Services	Patients are informed that language interpreter services may be necessary and that these services may not be immediately available.
Consent for Services	Patients must consent to the use and disclosure of their health information as described in the Notice of Health Information Privacy Practices.

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Misconceptions

Misconceptions about the Planned Parenthood Proof form can lead to confusion and misinformation. Here are seven common misunderstandings:

The form is only for pregnancy tests. Many believe this form is solely for pregnancy testing. In reality, it encompasses various medical services, including discussions about birth control and sexual health.
All information is shared with third parties. Some people worry that their personal information will be shared without consent. Planned Parenthood prioritizes confidentiality, and information is only shared as required by law or with your permission.
You must have insurance to receive services. There's a misconception that insurance is a prerequisite for care. Planned Parenthood offers services regardless of insurance status, and they can assist with payment options.
The form is complicated and hard to understand. While it may seem lengthy, the form is designed to be straightforward. Staff members are available to help clarify any part of the form you find confusing.
Providing a password is mandatory. Some think that providing a password for test results is required. It’s optional and meant to enhance your privacy if you choose to use it.
You can’t change your mind after signing. Many believe that once they sign the form, they are locked into their choices. However, you have the right to change your mind about services at any time.
All staff members are medical professionals. There’s a notion that everyone involved in the process is a trained medical professional. In fact, some staff may be in training, but they work under strict supervision to ensure quality care.

Understanding these misconceptions can help you feel more confident and informed about your experience with Planned Parenthood.

Documents used along the form

When seeking services from Planned Parenthood, several forms and documents may accompany the Proof form. Each document serves a specific purpose in ensuring that patients receive the appropriate care while maintaining their rights and privacy. Below are some of the key documents often used in conjunction with the Planned Parenthood Proof form.

Patient’s Bill of Rights and Responsibilities: This document outlines the rights patients have when receiving care, as well as the responsibilities they hold. It emphasizes the importance of informed consent and respectful treatment.
Request for Medical Services: Patients use this form to formally request medical services. It includes an acknowledgment of privacy practices and ensures that patients understand the care they will receive.
Health Information Privacy Practices Notice: This notice explains how patients' health information will be used and protected. It assures patients that their confidentiality will be maintained throughout their care.
Power of Attorney for a Child Form: This document enables a parent or guardian to temporarily authorize another adult to make decisions for a minor child, which can be essential in situations where the parent is unavailable. For more details, visit California PDF Forms.
Consent for Treatment: This form confirms that patients consent to receive specific medical treatments or procedures. It ensures that patients are informed about the risks and benefits of the services provided.

These documents work together to create a safe and informed environment for patients. Understanding each form helps individuals navigate their healthcare experience more effectively.