Planned Parenthood

Western Pennsylvania

Medical Forms

With each visit, you will be asked to fill out some forms. The information on these forms helps us to evaluate your medical history and any health concerns. You can download PDF forms here and fill them out in advance of your visit. This will make your visit go faster.

Click on the appropriate forms below to download:

Family Planning Intake Form

Family Planning History Form

Abortion Services Intake Form

Abortion Services History Form

If you are currently or have previously been a patient at any PPWP health center and would like a copy of your records for yourself or your current health care provider, you can download those forms here:

Release of Records to Self

Release of Records to a Third Party

Select Plan for Women provides family planning services for women who meet eligibility requirements. If you think you may be eligible for Select Plan for Women please print and fill out the application below. Bring this application along with the required documentation to your family planning visit. By filling this paperwork out in advance it will allow your visit to go faster.

 

Select Plan for Women Application

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Medical Forms