Planned Parenthood Greater Memphis Region
2430 Poplar Avenue, Suite 100, Memphis, TN 38112 (901) 725-1717
REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES
PUT LABEL HERE
PATIENT # ____________________________
NAME OF PATIENT ___________________________________
DATE OF BIRTH ____________________________
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
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
Greater Memphis Region 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.
Revised December 2012
PPGMR Manual of Medical Standards and Guidelines
Confidential property of Planned Parenthood Greater Memphis Region, Inc.