Printable Planned Parenthood Proof Form

• When filling out the Planned Parenthood Proof form, ensure that all personal information is printed legibly. This includes your name, address, and contact details, which are crucial for effective communication.

• Be aware that the form includes a section for your preferred contact methods. Choose how you wish to be contacted regarding your test results—whether by phone or mail. This helps maintain your privacy and ensures you receive important information in a timely manner.

• Take note of the medical screening section. This part is vital for assessing your health status and understanding your reasons for the test. Be honest about your symptoms and any history of reproductive health issues.

• Understand that your confidentiality is a priority. The form outlines how your information will be handled and emphasizes that your health details will be kept private, in line with health information privacy practices.

• Finally, remember to ask questions if anything is unclear. The staff is there to help you understand the form and the services you will receive. Your comfort and understanding are essential.

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 includes sections for personal details, medical history, and consent for treatment while ensuring patient confidentiality.

How do I fill out the form?

To fill out the form, you should print legibly and provide accurate information in each section. This includes your name, address, contact details, and medical history. Be sure to check the appropriate boxes for your preferences regarding communication methods and any relevant medical conditions. If you have questions while completing the form, staff members are available to assist you.

What happens to my information?

Your information is treated with the utmost confidentiality. Planned Parenthood is committed to protecting your privacy and will only use your information for medical purposes. They may contact you with test results or other important information through the methods you select, such as phone or mail.

Can I receive test results via email?

No, you cannot receive test results via email. The form specifies that your email address cannot be used for this purpose. Instead, you can choose to receive results through a phone call or mail, and you will need to provide a password for phone communication.

What if I need assistance understanding the form?

If you require assistance understanding the form, you should inform the staff. They can provide explanations and answer any questions you may have. Additionally, if you need language interpreter services, you should communicate this need to the staff, who will do their best to accommodate you.

What should I do if I have a medical emergency?

In case of a medical emergency, you should seek immediate care from an emergency medical facility. The form includes a section where you will be informed about how to obtain emergency care. Always prioritize your health and safety by acting quickly in emergencies.

Is there a fee for services?

While the form does not explicitly mention fees, it is important to understand that you may be responsible for any costs associated with tests or treatments. If you have questions about payment or insurance, you should ask the staff for clarification before receiving services.

What if I change my mind about receiving services?

You have the right to change your mind at any time regarding the services you wish to receive. The form states that your consent is voluntary, and you can withdraw it if you feel uncomfortable or if your situation changes.

How can I provide feedback or file a complaint?

If you have feedback or wish to file a complaint regarding your experience, you can refer to the Patient Complaints policy mentioned in the form. Planned Parenthood encourages open communication and is committed to addressing any concerns you may have.

Planned Parenthood Proof - Usage Instruction

Filling out the Planned Parenthood Proof form is an important step in ensuring that you receive the care you need. The information you provide will help the clinic understand your medical history and current situation. After completing the form, you will be able to proceed with your appointment, where you can discuss any questions or concerns with the healthcare staff.

1. Begin by printing the form legibly.
2. Check the box indicating you have received a copy of the Patient’s Bill of Rights and Responsibilities and Patient Complaints policy.
3. Fill in your last name, first name, and middle initial.
4. Provide your address, including apartment number (if applicable), city, state, and zip code.
5. Enter your employer's name and your email address (note that this cannot be used for test results).
6. List your home phone number, cell phone number, and work phone number.
7. Provide the name and phone number of an emergency contact.
8. Indicate how you prefer to be contacted for test results by checking the appropriate boxes (phone call or mail).
9. Set a password for receiving test results over the phone.
10. Fill in your date of birth and select your sex.
11. Provide your monthly income and family size.
12. Choose your preferred pronoun.
13. Indicate whether you have a living will by checking yes or no.
14. Describe how you heard about Planned Parenthood by checking the appropriate box.
15. Select your race and ethnicity from the options provided.
16. Indicate your highest level of education completed.
17. Complete the medical screening section, including the first day of your last menstrual period and whether it was normal.
18. Check the reason for your test and the results you hope to see.
19. Answer the questions regarding your current health status and any history of pregnancy-related issues.
20. Sign and date the form where indicated.