Planned Parenthood Consent Form

The Planned Parenthood consent form is a document that patients must sign in order to receive care at a Planned Parenthood health center. The form outlines the type of care that the patient will receive, as well as the risks and benefits of the procedure. The form also explains the patient's rights and responsibilities, and gives the patient the opportunity to ask questions and get more information about the procedure.

Time to complete

3 minutes

Eligibility

You can fill the Planned Parenthood consent form if you are a pregnant woman and want to get an abortion procedure done.

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Questions for Planned Parenthood Consent Form

1.

Patient Name

The answer should be a text input.
2.

Age

The answer should be a single choice:
  1. Under 18
  2. 18-24 years old
  3. 25-34 years old
  4. 35-44 years old
  5. 45-54 years old
  6. Over 55
3.

Partner's Name

The answer should be a text input.
4.

Phone Number

The answer should be a phone number.
5.

Address

The answer should be a text input.
6.

Name of Doctor/Gynecologist

The answer should be a text input.
7.

Doctor/Gynecologist's Number

The answer should be a phone number.
8.

Hospital Name

The answer should be a text input.
9.

Hospital Address

The answer should be a text input.
10.

Reason for abortion.

The answer should be a single choice:
  1. Not financially prepared
  2. Bad timing, not ready, or unplanned
  3. Interferes with educational or job plans
  4. Partner-related reasons
  5. Health-related reasons
  6. Not emotionally or mentally prepared
11.

Please Specify your reason for abortion.

The answer should be a text input.
12.

How many weeks pregnant are you?

The answer should be a text input.
13.

Do you have any medical conditions that we should be aware of?

The answer should be a text input.
14.

Have you discussed everything regrading your abortion procedure with your gynecologist?

The answer should be a single choice:
  1. Yes
  2. No
15.

Is this your first abortion?

The answer should be a single choice:
  1. Yes
  2. No
16.

Can you submit all the medical documents supporting your abortion reason.

File needs to be uploaded.
17.

Do you give your consent for abortion?

The answer should be a single choice:
  1. I agree
  2. I disagree
18.

Signature

The answer should be a signature.
19.

Date

The answer should be a date input.

Similar Ideas

  • State-Specific Informed Consent for Abortion
  • Informed Consent for Medical Abortion
  • Parental Consent for Abortion Form
  • Informed Consent for Sterilization
  • Informed Consent for Emergency Contraception

Here are some FAQs and additional information
on
Planned Parenthood Consent Form

What information is required on the Planned Parenthood Consent Form?

The Planned Parenthood Consent Form must include the patient's name, date of birth, and signature. Additionally, the form must list the specific Planned Parenthood service or treatment that the patient is consenting to receive.

How does a minor get consent to receive services from Planned Parenthood?

There are a few ways that a minor can get consent to receive services from Planned Parenthood. The first way is for a parent or guardian to give their permission for the minor to receive services. The second way is for the minor to receive a “judicial bypass” which means that a judge gives permission for the minor to receive services. The third way is for the minor to receive a “medical waiver” which means that a doctor gives permission for the minor to receive services.

What services does Planned Parenthood provide?

Planned Parenthood provides a variety of services including- birth control, STD testing and treatment, cancer screenings, and abortion.

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