In order to provide optimum healthcare, we ask that you complete medical paperwork before your visit. Completing these forms before your visit saves time at the Center and allows you privacy and access to information.
Please download, print single sided and fill out the forms below and bring them with you to your visit. Fill out the forms in black or blue ink only and check or cross the boxes off individually.
Client Intake Form English
Request for Medical Services and HIPAA English
Client Intake Form Spanish
Request for Medical Services and HIPAA Spanish
If you are a Pennsylvania woman between the ages of 18 - 44, without health insurance, who needs help paying for your reproductive health care, you may qualify for Pennsylvania's SelectPlan program. To save time and extra trips back to the health center, please see what documents you will need to bring.
SelectPlan Application English
SelectPlan Application Spanish
If you are moving and would like your Medical Records sent to your new Planned Parenthood health center or doctor's office, please complete this form. You can fax or mail it to your health center. Please allow at least ONE week and call before coming in to pick up your records.
Authorization for Release of Protected Health Information English
Autorizacion de Divulgacion de Informcion de Salud Protegida Spanish
