Patient Contact And Statistical Info Form

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PATIENT CONTACT AND STATISTICAL INFO
Full Name:
For contraceptive patients: The person(s) listed below will not have
Previous/Maiden Name:
access to your medical records.
I give permission for the following person(s) to pick up my supplies:
Social Security #: ____ ____ ____ - ____ ____ - ____ ____ ____ ____
Name
Relationship to you
Date of Birth: _________ / _________ / _________
Home Address:
May we send mail to this address? Yes  No
(Our name will not appear on the envelope)
Street:
City:
I understand Planned Parenthood is required to contact me regarding abnormal
test results. Confidentiality will be maintained as much as possible, but If
State:
Zip:
Planned Parenthood cannot contact me via the information I have provided, I
understand confidentiality may need to be broken.
x
/
/
Mailing Address:
 Same as Home Address
Patient Signature
Today’s Date
PPSFL must have a mailing address where we can contact you. If we
cannot send mail to your physical home address, please provide a
STATISTICAL INFORMATION REQUIRED BY THE STATE OF NEW YORK:
mailing address here. (Our name will not appear on the envelope.)
Sex:
 Female
 Male
 Other
In Care of:
Race: Please check all that apply:
 American Indian
 Alaskan Native
Asian
Street:
Black/African American
White
Other
Pacific Islander/Hawaiian Native
Are you Hispanic?
Yes
No
City:
Interpreter needed?  Yes
 No
State:
Zip:
County:
 Friend or family
How did you find out about PP’s services:
 Planned Parenthood Education Program
 Planned Parenthood website  Mobile Phone app  Radio Ad
Home Phone: ____________________________ 
OK to say PP
 Newspaper Ad  TV Ad  Phone Book
 My Insurance Company  Private Physician
OK to say Dr’s Office
Use Code Name ________
No message
Social Services Agency (WIC, DSS etc)  My Insurance Company
 Other _______________________
Cell Phone: ________________________________
OK to say PP
What is the highest grade of school you have completed?
(Circle one)
OK to say Dr’s Office
Use Code Name ________
No message
6
7
8
9
10
11
12
13
14
15
16
17+
Work Phone
: _________________________________
OK to say PP
OK to say Dr’s Office
Use Code Name ________
No message
Marital Status:
Single
Separated
Living with Partner
Married
Divorced
Widowed
Emergency Phone
:
Other Provider: 
Check this box if you use another clinic/provider as your
In case of an emergency, please provide information about someone we may
main source of healthcare.
contact who will ALWAYS know how to reach you. Minors must provide the
name of an adult (if not a parent, then another relative or adult friend is
FEMALE PATIENTS ONLY: # of living children:
# of births:
sufficient).
# of times pregnant:
Date last pregnancy ended:
Name:
Phone: (
)
-
Patient Label:
Relationship to you:
Y:\PTServices\PPSFL\PATIENT INFORMATION\Patient Contact Form 4.13.doc

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