FAMILY PLANNING PR OGR AM
MEMORANDUM OF UNDERSTANDING
You are about to take pat1 in the Columbus County Family Planning Program which supplies patients with the
necessary means to plan families. The following agreement outlines the responsibilities of the clinic and the
patients.
I.
The clinic will provide you with the following services:
a. Laboratory tests of your blood and wine including Sickle Cell, Rubella, HIV, Syphilis,
Hemoglobin, etc. as determined by the clinician.
b. Checking of your blood pressure, weight, height, and BMI.
c. Interpretations of personal and family medical histories.
d. Physical examinations, including Pap Smears, Gonorrhea/Chlamydia cultures, etc. and/or
others as determined by the clinician.
e. Discussion of all methods used in planning families, including fertility awareness.
f. The appropriate method of contraception for your personal needs.
g. Counseling and referral by nurses when necessary for pregnancies, abortion,
sterilization, individual and family problems and other sexual issues.
h. Provide gynecological services such as d diagnosis and treatment of vaginitis or sexually
transmitted infections.
i. Infertility counseling and referral.
j. Regularly y scheduled checkups in the clinic;
Annual new Contraceptive patients
New Patients - Initial visit and 3 month re-visit, then annual visit -I year check up
Depo Provera-every- every 12 weeks for repeat injections
Diaphragm patients-2 weeks and annually thereafter.
Foam and condom – Patients annually.
Implanon insertions and 2 weeks site check the annually
II.
You are expected to take part in your care and to do as follows:
a. Have an appointment and be on time.
b. Contact the clinic if you cannot keep the appointment.
c. Contact the clinic if you move or do not wish to continue
d. Immediately y report to the clinic any serious side effects from the method of contraception
you are using.
e. Bring pay check stubs or some proof of income to determine the amount you will pay for
services of this clinic.
III.
Important Notices:
a. All information gathered fro m you by the clinic is strictly confidential & cannot be released
without your written consent.
b. The Health Department will send you a letter if you have a positive Test.
I have read the above statements and I understand their meaning for me. I have been given a copy of this
consent form to take with me and refer to as needed. I hear by consent to pat1icipate in the Columbus County
Family Planning Program and will fulfill the duties expected of me.
Signature of Patient
_
__
__ Date _
See back of page for emergency information and give patient a copy
_
Columbus County Health Department
304 Jefferson St.
Whiteville, N. C. 28472
910-640-6615
Depo-Provera Warning
• Repeated, very painful
headaches
• Heavy bleeding
• Depression
• Severe, low stomach pain
• Pus, long-lasting pain or
bleeding at the site of the
shot
Emergency Contraception
• If your birth control fails, or
• You have sex without using
birth control and do not
want to get pregnant.
Call the family planning clinic as
soon as possible.
• Ask about emergency
contraception\
For Appointment Call:
Columbus County Health
Department at 910-640-6615
Weekends or Emergencies go to
Columbus Regional Health Care
System Emergency Department.
Oral Contraception (pills)
Hospital number is 910-642-8011
• Stomach pain (severe)
• Chest pain (sever, cough,
• It can reduce the risk of
shortness of breath, sharp
pregnancy when you take it
Name:
_
pain when you breathe in)
within 120 hours (5days).
• Headache(severe, dizziness,
weakness
or
numbness,
If the clinic is closed, call
_
especially if on one side)
1-888-Not-2-Late (1-888-668-2528) Medical Record#
• Eye problems (vision loss or
blurring(, speech problems
• Severe leg pain (calf or thigh)