Patient Forms
Want to apply for no-cost birth control? Need a copy of your medical records? Find the form you need below.
No-Cost Birth Control Application
- No-Cost Birth Control Application (PDF)
No insurance? You may qualify for no-cost birth control. Fill out this form and bring it to your visit to apply.
Medical Records Release Forms
Need a copy of your medical records? Please read the descriptions below and fill out the form that applies to you, then fax the completed form to 651-696-5543 or scan to [email protected].
Minnesota Clinic Patients
- Medical Records Release TO Planned Parenthood-MN (PDF)
Use this form if you want to send Planned Parenthood Minnesota, North Dakota, South Dakota a copy of your records from another provider. Note: You don't need this form to switch between Minnesota and South Dakota Planned Parenthood clinics. - Medical Records Release FROM Planned Parenthood-MN (PDF)
Use this form if you want to send a copy of your Planned Parenthood Minnesota, North Dakota, South Dakota medical records to another provider or third party. - Medical Records Release to Self (PDF)
Use this form to request a personal copy of your medical records.
South Dakota Clinic Patients
- Medical Records Release TO Planned Parenthood-SD (PDF)
Use this form if you want to send Planned Parenthood Minnesota, North Dakota, South Dakota a copy of your records from another provider. Note: You don't need this form to switch between Minnesota and South Dakota Planned Parenthood clinics. - Medical Records Release FROM Planned Parenthood-SD (PDF)
Use this form if you want to send a copy of your Planned Parenthood Minnesota, North Dakota, South Dakota medical records to another provider or third party. - Medical Records Release to Self (PDF)
Use this form to request a personal copy of your medical records.
Questions about which form to fill out? Give us a call at 1-800-268-9150.