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: Voss First Name: Jennifer Middle Initial: L
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)
st
1 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? If Spotting/Bleeding
yes, what method? ___________________ Fever
For how long? Abdominal Pain
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
Pelvic Infection or tried to 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
symptoms of pregnancy? ask?
If yes, explain: Has your partner ever tried to force or pressure you
to become 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  Explained limitations of test (morning
Tests urine sample/time since last period) 
V H CIIC HOPE STIs Advised re-test in 1-2 weeks
BCM Options CIIC Contraceptive Prenatal Care  Discussed blood PT
 Implant  Advised RTO if no menses for 3
CIIC Pill,Patch, CIIC IUC Adoption consecutive months
Ring If Minor: Encouraged parental
CIIC DMPA CIIC Barriers (condoms) Abortion involvement
CIIC POPs CIIC Essure CI Sx of Early
Pregnancy

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 _______________