Youngstown Area Centers
These forms can only be used at these Planned Parenthood of Northeast Ohio health centers:
We have several forms that you can print out ahead of time and bring with you to your appointment. NOTE: Please fill out the forms with black ink.
If you are a new patient, you will need to complete these forms before your first visit, either at home, or after arriving at the Health Center.
Medical History Form: Your basic medical information. NOTE: Please fill out form no sooner than 2 days before your appointment.
Request for Provision of Medical Services: This is a consent form for us to provide services to you, the patient. This form is two pages, please make sure you print out both. NOTE: Please do not sign this form until one of our staff reviews it with you.
Records Release of Information To PPMV: Do you need your doctor to send your records to PPMV? Print this form, and take it to your doctor's office to have your records transferred to us.
Release of Information From PPMV: Do you need your PPMV records sent to your doctor? Print this form, fill it out, and send it to PPMV. Mailing and faxing information for PPMV health centers is included on the form.
The information you provide on all of these forms is strictly confidential.
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