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In recent years, the Planned Parenthood Proof form has become an indispensable part of the services offered by Planned Parenthood of Southeastern Virginia, providing a comprehensive approach to patient care and confidentiality. Located in Hampton and Virginia Beach, this organization ensures that every individual seeking medical services, from urine pregnancy tests to sexual health screenings, is treated with respect and informed consent. The form meticulously records personal details, medical screening information, and preferred methods of communication, underscoring Planned Parenthood's commitment to privacy and personalized care. Alongside facilitating essential medical services, the document doubles as an educational tool, guiding patients through their rights, the array of available medical services, and the import of acknowledging the reception of health information privacy practices. This blend of care, confidentiality, and education encapsulates the Planned Parenthood mission, ensuring that individuals are not only medically supported but also informed and respected throughout their healthcare journey.

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 _______________

Click for PDF Form

File Characteristics

Fact Name Description
Organization Name Planned Parenthood® of Southeastern Virginia
Location Addresses 403 Yale Drive, Hampton, VA 23666 and 515 Newtown Road, Virginia Beach, VA 23462
Contact Information Hampton: (757)826-2079, Virginia Beach: (757)499-7526
Service Provided Urine Pregnancy Test
Patient Rights and Policies Patient’s Bill of Rights and Responsibilities and Patient Complaints policy provided
Confidentiality Assurance Commitment to maintaining confidentiality through selected contact methods
Medical Screening and Assessment Includes history of menstruation, reason for test, current symptoms, and a completed assessment by clinic staff
Patient Education on Results Guidance provided for both negative and positive pregnancy test results, including further testing and available options
Governing Law(s) Required reporting of positive results for certain sexually transmitted infections to public health agencies as per Virginia law

Steps to Writing Planned Parenthood Proof

Filling out the Planned Parenthood Proof form is a crucial step for accessing certain health services. The form includes sections for personal information, medical history, and consent. With thoughtful attention, the process can be completed accurately to ensure the best possible care. Follow these instructions to fill out the form correctly.

  1. Start with the header information. Check the box next to “URINE PREGNANCY TEST” if that is the service you are seeking.
  2. Provide your full name, including last, first, and middle initial.
  3. Fill in your address details: street address, apartment number, city, state, and zip code.
  4. Include your employer's name if applicable.
  5. Enter your email address, remembering it cannot be used for test results.
  6. List your contact numbers: home, cell, and work phone numbers.
  7. Provide an emergency contact, including their name and phone number.
  8. Indicate your preferred method(s) of contact by checking the appropriate box(es) - Phone Call or Mail. Additionally, provide a password for phone communication.
  9. Fill in your date of birth and select your sex (Female or Transgender).
  10. Specify your monthly income, family size supported by you, and preferred pronoun.
  11. Answer the question regarding a living will by checking Yes or No.
  12. Indicate how you heard about Planned Parenthood by checking the appropriate box and providing additional details if you select "Other."
  13. Select your race, ethnicity, and if you are Hispanic or not.
  14. Choose the highest level of education you have completed.
  15. Under the medical screening section, provide information about your last menstrual period, including the first day and whether it was normal. Also, specify your reason for the test and the test result you hope to see.
  16. Answer the questions about your current health status, birth control use, and potential symptoms.
  17. The section titled "ASSESSMENT (COMPLETED BY CLINIC STAFF)" will be filled out by the clinic staff.
  18. In the "Request for Medical Services and Acknowledgement of Receipt of Notice of Health Information Privacy Practices" section, enter the date and acknowledge the receipt of privacy practices by signing your name and providing the date at the bottom.
  19. If a guardian or relative's signature is legally required, ensure they sign their name, disclose their relationship to you, and include the date.
  20. Familiarize yourself with the patient education section, understanding that clinic staff will guide you through this information during your visit.

After you complete and submit the form, the staff at Planned Parenthood will review your information and provide you with the necessary services. You will have the opportunity to discuss any questions or concerns with a clinician. Remember, your information and visit are treated with confidentiality and respect. Planned Parenthood is committed to providing you with the care and guidance you need.

Important Details about Planned Parenthood Proof

What is the Planned Parenthood Proof form and why do I need to fill it out?

The Planned Parenthood Proof form is a document that you complete when seeking services at Planned Parenthood Southeastern Virginia. It documents your personal information, health history, and consent to receive medical services. Filling out this form is crucial because it helps the healthcare providers offer tailored care based on accurate and comprehensive information. It also includes your acknowledgment of receiving the Notice of Health Information Privacy Practices, ensuring you are aware of how your health information will be used and protected.

How can I choose the methods by which Planned Parenthood contacts me with test results or other information?

Planned Parenthood Southeastern Virginia respects your privacy and offers various methods for contacting you, including phone calls and mail, to share test results or other important information. You can indicate your preferred contact methods directly on the form by checking the appropriate boxes. Additionally, you can provide a password for receiving test results over the phone, adding an extra layer of confidentiality to your information.

What should I do if I need a language interpreter for my healthcare visits at Planned Parenthood?

If you require a language interpreter to understand the written or spoken information during your healthcare visits at Planned Parenthood, it's important to inform the staff. While free interpretive services may not be immediately available, Planned Parenthood will make efforts to refer you to another healthcare facility that can meet your needs. This ensures you have access to the necessary care and fully understand the information and services being provided.

Is my personal and health information kept confidential by Planned Parenthood?

Yes, Planned Parenthood Southeastern Virginia is committed to maintaining the confidentiality of your personal and health information. The form includes a section where you acknowledge receiving the Notice of Health Information Privacy Practices, which outlines how your information is used and protected. The form also explains that information related to certain sexually transmitted infections, if positive, must be reported to public health agencies by law, but outside of such requirements, your information is handled with strict confidentiality. You also consent to the use and disclosure of your health information as described within the Notice of Health Information Privacy Practices.

Common mistakes

One common mistake that individuals make when filling out the Planned Parenthood Proof form is not printing legibly. This form serves as a critical touchpoint for healthcare provisioning and communication; therefore, clarity in handwriting ensures accurate recording and processing of personal data, including names, addresses, and sensitive medical information. Unclear handwriting can lead to misinterpretation or misfiling of vital patient details, impeding the delivery of care and communication.

Another frequent error involves skipping important sections of the form, such as the 'Emergency Contact' details and preferences for contact methods. These details are essential for Planned Parenthood to maintain crucial contact with the patient, especially in situations requiring urgent communication about test results or follow-up care. Omitting this information can significantly delay the provision of necessary medical feedback or interventions.

Some patients neglect to provide a password for receiving test results over the phone. This password is a safeguard, designed to protect the patient's privacy by ensuring that test results are only disclosed to authorized individuals. Without this security measure, there's an increased risk of breaching patient confidentiality, which can lead to privacy concerns and anxiety for the patient.

A common oversight is the inaccurate or incomplete reporting of personal health history and current health status in the ‘MEDICAL SCREENING’ section. Accurate reporting of menstrual history, reasons for the test, current symptoms, and contraception use is essential for clinicians to provide appropriate care. Missing or inaccurate information can mislead healthcare providers, resulting in suboptimal care or inappropriate recommendations for the patient’s specific healthcare needs.

Similarly, failing to provide detailed answers to sensitive questions regarding sexual and reproductive health, such as past experiences of abuse or coercion and current safety concerns within a relationship, further complicate the ability of Planned Parenthood to offer comprehensive care. These omissions hinder the capacity to provide targeted support and resources that address the full scope of the patient's health and well-being.

Lastly, the inability or failure to properly acknowledge receipt of the Notice of Health Information Privacy Practices by not signing the acknowledgment section undermines the legal and procedural compliance. This signature is crucial not only for compliance with health information privacy laws but also for confirming the patient's understanding and agreement to how their health information will be used and disclosed. Such an oversight can create liabilities and misunderstandings regarding patient rights and the confidentiality of their health information.

Documents used along the form

When utilizing the Planned Parenthood Proof form, there are several other documents and forms that individuals might find themselves needing either for verification, support, or additional medical and legal processes. Below is a list and brief description of each.

  • Patient Bill of Rights and Responsibilities: This document outlines the rights and responsibilities of the patient while receiving care, ensuring they are aware of their entitlements and obligations.
  • Patient Complaints Policy: Provides a clear procedure for patients to follow if they need to file a complaint about the care or service received, ensuring their voices can be heard.
  • Notice of Health Information Privacy Practices: This important document informs patients about how their medical information may be used and disclosed, and how they can get access to this information, ensuring privacy and confidentiality.
  • Authorization for Release of Health Information: Often required to share medical records between providers or with other parties, this form requires the patient's consent to disclose health records.
  • Medical History Form: Captures a patient's past medical history, surgeries, allergies, and other pertinent health information, ensuring comprehensive care.
  • Consent to Treatment Form: A document where the patient consents to receive medical treatment, acknowledging they are informed about the procedures and their risks.
  • Proof of Income Form: May be necessary for patients seeking assistance based on income levels for certain medical services or programs.
  • Emergency Contact Form: This form lists contact information for use in case of a medical emergency, ensuring medical providers can reach someone close to the patient if needed.
  • Insurance Information Form: Collects details about a patient's insurance provider, policy number, and other relevant information, necessary for billing purposes.
  • Advanced Directive or Living Will: Helps in outlining the patient's wishes regarding their medical treatment and decisions, especially in situations where they may not be able to express their preferences.

Each of these documents plays a crucial role in ensuring that the care provided is in accordance with the patient's rights, wishes, and health needs. They help in creating a transparent, respectful, and efficient healthcare environment.

Similar forms

The Health Insurance Portability and Accountability Act (HIPAA) Authorization for Release of Information form shares similarities with the Planned Parenthood Proof form, particularly in handling sensitive health information. Both are designed with the patient's privacy in mind, emphasizing confidentiality and the precise conditions under which information can be disclosed. While the Planned Parenthood form seeks consent primarily to provide medical services and acknowledge privacy practices, the HIPAA form broadens the scope to include sharing information with specified individuals or entities for reasons beyond immediate care, like insurance processing or family communication.

Medical History Form, commonly used in various healthcare settings, collects comprehensive health-related information from the patient, similar to the screening section of the Planned Parenthood Proof form. Both documents are essential for ensuring that healthcare providers have a full understanding of the patient's health background, risks, and concerns, aiding in tailored treatment and care. However, the content specifics differ, with Planned Parenthood focusing more on reproductive health, while the Medical History Form covers a broader range of health aspects.

The Informed Consent for Medical Treatment form, used across healthcare facilities, shares the purpose of ensuring that patients are fully aware of the details and implications of the treatment they are to receive. Like the Planned Parenthood form, it emphasizes the patient's right to understand the potential benefits and risks associated with the proposed care. Both documents ensure the patient's autonomy is respected, providing a foundation for informed decision-making regarding their health care.

Emergency Contact and Medical Information forms, utilized in both healthcare and non-healthcare settings, like schools or workplaces, collect critical information that might be needed in an urgent situation. Similar to parts of the Planned Parenthood Proof form, they ensure that contact numbers, health issues, and preferences are documented and accessible if swift action is needed. While the primary intent may be for use in emergencies, the underlying goal of documenting such information is to expedite care and communication when time is of the essence.

The Patient Registration Form is another document with resemblances, primarily used at the initial visit to a healthcare provider or hospital to capture key personal and insurance information. Like the Planned Parenthood form, it might include demographic information, insurance details, and contact information, forming the basis for the patient’s record. Both documents lay the groundwork for a relationship between the patient and the healthcare facility, ensuring that administrative and foundational clinical data is captured accurately.

Sexual Health History forms, found in clinics specializing in sexual health, gather detailed information about an individual's sexual behavior, contraceptive use, and history of sexually transmitted infections (STIs). These forms, analogous to portions of the Planned Parenthood Proof form, prioritize the collection of sensitive information to provide appropriate care and counseling tailored to the patient's specific sexual health needs. While focusing on a specialized aspect of health, both documents underscore the importance of privacy and informed patient care in sensitive areas.

Last but not least, the Advance Healthcare Directive (or Living Will) is a document that allows individuals to state their wishes for medical treatment in scenarios where they are unable to communicate. While serving a different primary purpose compared to the Planned Parenthood Proof form, both documents touch upon the subject of personal healthcare preferences and the importance of documenting such preferences to guide future care. Each plays a pivotal role in advocating for the patient’s values and desires regarding their health treatment and care.

Dos and Don'ts

When filling out the Planned Parenthood Proof form, it's crucial to provide accurate and complete information to ensure the best possible care. Here are some important do's and don'ts to guide you through the process:

  • Do print legibly to ensure that all information is readable and can be accurately processed by clinic staff.
  • Do check the appropriate boxes that apply to your situation, especially when it comes to methods of contact and receiving test results.
  • Do provide a reliable phone number and select a secure password for receiving test results over the phone, ensuring your privacy is protected.
  • Do accurately report your medical history, including the first day of your last menstrual period and any symptoms you are currently experiencing, to provide the clinic with necessary health information.
  • Do honestly answer questions about your current health status, including whether you are experiencing signs or symptoms of pregnancy or if you have a history of certain medical conditions.
  • Do not leave any sections blank that are applicable to you. If a question does not apply, it's better to mark it as "N/A" or "None" rather than leaving it empty, which could be seen as an oversight.
  • Do not use an email address for receiving test results, as indicated in the form instructions. Make sure to comply with the stated communication preferences.
  • Do not provide false information or omit important details about your health. This can lead to inadequate care or inappropriate treatment.
  • Do not forget to indicate your pronoun and income, as these details are crucial for personalized and equitable care provision.
  • Do not sign the consent form without fully understanding what you are agreeing to. If you have questions, ask a clinic staff member for clarification.

Completing the Planned Parenthood Proof form with attention to detail and honesty ensures that you receive the most appropriate care based on your specific health needs and circumstances.

Misconceptions

When discussing the Planned Parenthood Proof form, several misconceptions can lead to misunderstanding or misrepresenting what the form represents and the practices of Planned Parenthood. Here are four common misconceptions cleared up:

  • Misconception 1: The form only serves those seeking abortion services. The Planned Parenthood Proof form covers a wide range of services beyond pregnancy-related options, including medical screenings for various health concerns, contraceptive methods, and sexually transmitted infections (STIs) testing and prevention. This showcases Planned Parenthood’s comprehensive approach to sexual and reproductive health.
  • Misconception 2: Patient information is not kept confidential. Confidentiality is a cornerstone of Planned Parenthood's services, as clearly stated in the form. Patients are informed that their confidentiality will be maintained according to the Notice of Health Information Privacy Practices. The form even goes as far as letting patients decide on the method of contact, like phone calls or mail in plain envelopes, which further ensures privacy and confidentiality.
  • Misconception 3: Contact information is used for unsolicited communication. The form emphasizes that contact information provided by patients is used specifically for communicating results of tests or necessary follow-up information. Patients also have the autonomy to choose how they prefer to be contacted, ensuring that communication is done as per their comfort and consent.
  • Misconception 4: Planned Parenthood does not respect patient autonomy or consent. It is clear from the form that informed consent is a critical component of Planned Parenthood’s services. Patients are made aware of their right to ask questions, receive information about tests, treatments, and procedures, and understand that they can refuse services or change their mind at any time. This underlines the organization's commitment to respecting patient choices and autonomy.

Understanding the content and purpose of the Planned Parenthood Proof form is essential in dispelling myths and acknowledging the comprehensive care Planned Parenthood offers to individuals seeking reproductive and sexual health services.

Key takeaways

Filling out the Planned Parenthood Proof form is an important step in receiving medical services and acknowledging health information privacy. Here are four key takeaways to remember:

  • It's vital to print legibly to ensure all your information is accurately captured. This includes personal details, medical history, and preferences for receiving test results and communications.
  • Confidentiality is a cornerstone of the services provided. You'll be asked to specify preferred methods of contact to maintain privacy, such as phone calls or mail, and to provide a password for receiving test results over the phone.
  • The form collects comprehensive health information, including details about your menstrual cycle, reason for testing, current symptoms, birth control methods, and history of pregnancies. This helps tailor the services to your specific needs.
  • Consent is a critical component. By signing the form, you acknowledge that you've received information about the procedures you're consenting to, understand your privacy rights, and agree to the use and disclosure of your health information as outlined in the Notice of Health Information Privacy Practices. You're also reminded that services are voluntary, and you can change your mind about proceeding with them at any time.

Remember, the staff at Planned Parenthood are available to answer any questions and ensure you fully understand the information and consent you're providing. Don't hesitate to ask for clarification on anything you find confusing.

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