PATIENT INFORMATION PLEASE PRINT - Planned Parenthood - plannedparenthood 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering today's date and your chart number at the top of the form.
  3. Fill in your personal information, including last name, first name, middle name, race, and Hispanic origin. Ensure all fields are completed accurately.
  4. Provide your address details, including street address, city/state, ZIP code, and apartment number if applicable.
  5. Indicate your marital status and preferred language from the provided options.
  6. Enter your birth date and age. Select your sex by checking the appropriate box.
  7. Complete the contact information section with home phone, cell phone, and social security number.
  8. Answer how you were referred to the clinic and provide details about your pregnancy history.
  9. In the income/insurance section, indicate your household income and payment method for today’s visit.
  10. Fill out emergency contact information as required.
  11. Finally, review all entered information for accuracy before signing at the bottom of the form.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
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Planned Parenthood Great Rivers is excited to now offer the online patient portal. MyChart provides you with online access to your medical record. It can help you access your health records and communicate with your providers.
We encourage all Planned Parenthood patients who we serve in Alaska, Hawaiʻi, Idaho, Indiana, Kentucky and Washington, new and existing, to sign up for MyChart. Patients seeking telehealth (virtual visits) are required to sign-up for MyChart prior to their telehealth appointment.
We may disclose health information about you to doctors, nurses, technicians, health students, volunteers or other personnel who are involved in taking care of you.
After you visit PPHP, we will not notify your parents of the care you received if you do not want them to know. Your parents cannot even access your medical records without your permission.
At your first visit, a Planned Parenthood staff member will: Measure your weight and blood pressure. Note your gender identity, pronouns and sex assigned at birth in your medical record; of note, we ask all patients for this information in order to best care for them, regardless of the reason for their visit.
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People also ask

Be sure to bring these items to your appointment: Photo identification. Insurance card, if you have coverage. Payment for services is required if you do not have insurance or do not plan to use insurance. Accepted forms of payment include:
Getting Started with MyChart If you have an upcoming visit, your care team can send you an email with an activation code after your appointment. If you do not have an upcoming visit, you can call the call center or health center to request an activation code. You must be a current patient and have an email address.

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