This online form will take you about 10 minutes to complete and will expedite your check-in process. If you prefer to complete the forms in our office, please arrive 10-15 minutes early for your appointment.
All questions marked with an * are required.
CONFIDENTIALITY, DISCLAIMER AND LIMITATIONS OF SERVICE
Pregnancy Resource Centers of Central Oregon (PRCCO) is a nonprofit, faith-based, charity organization. All of our services are free and many of the services are provided by volunteers. All our medical services are provided by licensed medical professionals.
Confidentiality: All information is kept confidential, except if reporting laws apply or if we believe or hear that you are in danger of hurting yourself or others. PRCCO uses a HIPAA compliant third-party computer program service for all client record storage and maintenance. We also use a third-party provider for online Learn2Earn education.
Consultations: The Pregnancy Resource Centers of Central Oregon client advocates are lay people, not necessarily licensed or degreed personnel. The consultation services obtained here are not intended as a substitute for professional counseling. Our center takes a holistic approach to healthcare, which means we address your physical, emotional and spiritual health.
Pregnancy Testing: The urine pregnancy test is 97% to 99% accurate; however, a physician must confirm the results of your test. Whether the test is positive or negative, you should follow-up with a licensed physician.
Ultrasound: The limited OB ultrasound is a medical service and is provided by a licensed Registered Nurse (RN) or Registered Diagnostic Medical Sonographer (RDMS) under the oversight of a local licensed Medical Director. The limited OB Ultrasound is performed only for purposes of confirming my pregnancy, detecting fetal cardiac activity and determining estimated gestational age. It is not for the purposes of diagnosing or detecting any medical problem or condition for my baby or me.
Abortion: We do not perform, offer, recommend or refer for abortions, the abortion pill, any type of medical or surgical abortion, abortion related services or abortifacients, but we do provide information and services so that you are equipped to make an informed choice about your pregnancy.
Adoption: We are not a licensed adoption agency and we are not affiliated with any adoption agencies. We offer information about adoption and can provide a list of several adoption agencies for review. Our endorsement of any adoption agency does not warranty their services nor do we receive any financial remuneration from any agency. We do not represent prospective adoptive parents nor assist them in their search for a child. If you decide to consult with an adoption agency, that agency is independent of PRCCO.
Referrals: Although we give referrals for medical care, professional counseling, housing, and other community services, we assume no legal responsibility for services provided by other agencies or individuals; nor are the views of these organizations or individuals necessarily the views of PRCCO.
Fees: All of our services are free of charge. PRCCO does not benefit financially from your decision regarding your pregnancy. We do not accept any form of payment or collect any insurance information.
Recording Devices: For the privacy of our clients, PRCCO and its agents do not consent to any recording, taping, photographing or videotaping on the premises. Any violation of this policy may result in prosecution.
By signing this form I am agreeing to hold Pregnancy Resource Centers of Central Oregon harmless from and against all claims or causes of action arising out of a referral by Pregnancy Resource Centers of Central Oregon. I have read and understand the above and hereby authorize the staff of this Center to discuss and render available services as necessary for my care. I have been provided the opportunity to review the PRCCO’s Notice of Privacy Practices.