Planned Parenthood Of Indiana & Kentucky
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1
2PLANNED PARENTHOOD OF INDIANA & KENTUCKY
Please use BLUE or BLACK ink only .
ID verified by staff
Today's Date: ____/____/20___
Chart Number: _____________________
Last Name: __________________________________First Name: ________________________ MI: _____
Social Security Number: ________-______-________
Birth Date: _______/_______/_______
Gender
Female
Male
Circle one
Address:
____________________________________________________________
Apt. #: __________
City:
State: ____________ Zip: _____________
What is your preferred language? ____________________________________
Marital Status:
Single
Married
Separated
Divorced
Widowed
Circle one
Are you a student?
Yes
No
If yes,
Full-Time
Part-Time
Circle one
Home Phone: (________) ________-__________
May we call you at home?
Yes
No
Circle one
Cell Phone: (________) ________-__________
May we call your cell phone?
Yes
No
Circle one
Email address:
What is the highest education level you have completed?
8th grade or Less
9th-12th grade/No Diploma
Circle one
High School Diploma (or GED)
Some College / No Degree
Associates Degree
Bachelors Degree
Post Graduate Degree (17-20)
Unknown
Employment:
Full Time
Part Time
Unemployed
Not seeking employment
Yes
No
May PPINK send you mail in a plain envelope?
If no, provide an alternate way to contact you.
Circle one
Yes
No
May we say it is PPINK if we need to call you?
If no, provide an alternate way to contact you.
Circle one
Alternate Contact Name:
Alternate Address:
City:
State:
Zip:
Phone:
Race:
White
Black
Asian
Multi-Racial
(circle all that apply)
Am Indian/Alaska Native
Native Hawaiian/Pacific Islander
Other
Ethnicity:
Hispanic:
Yes
No
Circle one
Total Weekly Household income before Taxes: $
(wages, disability, social security)
The Total number of people in the household supported by this income: _________
Emergency Contact:
Name: _________________________________________________________________
Phone: (_________) ________-___________ Relationship: _____________________
How did you hear about us?
____________________________________
Do you have Health Insurance or Medicaid?
Yes
No
Circle one
Do you want us to bill your insurance for the services provided to you today?
Yes
No
Circle one
If yes, please present your card to the front desk staff.
Insurance Policy
ID #
Policy Holder's Name:
Group #
Policy Holder's Address:
Policy Holder's Date of Birth:
Policy Holder's Relationship to patient:
You will be responsible for any supplies or lab fees not covered by your insurance.
Initials __________
In addition, if your Insurance Company is not in network, You will be expected to pay at the time of service.
I understand that information may be released from my medical record if I am having my services billed to an insurance company
: ___________________________________________
Signature
or third party.
Current Birth Control Method:
Desired Method:
Do you want to authorize someone to pick up your supplies for you?
Yes
No
Name (s):
Page 1 of 2
PPINK 144-0515
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