Go to Content Go to Navigation Go to Navigation Go to Site Search Homepage

REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

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.

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 of the Great Northwest 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).

We and our third partners use cookies and other tools to collect, store, monitor, and analyze information about your interaction with our site to improve performance, analyze your use of our sites and assist in our marketing efforts. You may opt out of the use of these cookies and other tools at any time by visiting Cookie Settings. By clicking “Allow All Cookies” you consent to our collection and use of such data, and our Terms of Use. For more information, see our Privacy Notice.

Cookie Settings

We, and our third-party partners, use cookies, pixels, and other tracking technologies to collect, store, monitor, and process certain information about you when you access and use our services, read our emails, or otherwise engage with us. The information collected might relate to you, your preferences, or your device. We use that information to make the site work, analyze performance and traffic on our website, to provide a more personalized web experience, and assist in our marketing efforts. We also share information with our social media, advertising, and analytics partners. You can change your default settings according to your preference. You cannot opt-out of required cookies when utilizing our site; this includes necessary cookies that help our site to function (such as remembering your cookie preference settings). For more information, please see our Privacy Notice.

Marketing

On

We use online advertising to promote our mission and help constituents find our services. Marketing pixels help us measure the success of our campaigns.

User Feedback and Session Replay

On

We use qualitative data from LogRocket, UserZoom, Hotjar and AB Tasty to learn about your user experience and improve our products and services. LogRocket allows us to view session replays.