EPS ON THE GO - Confirmation of Services

CONFIRMATION OF SERVICES
By signing below, both the patient and provider confirm that the exercise treatment scheduled according to the treatment plan was provided on the date and time specified below. This acknowledgment serves as a record of the completed session, ensuring mutual agreement and accountability for the care provided.
Printed Name of Patient or Personal Representative*
Relationship to Patient*
Put N/A if Consent is being signed by the patient
Signature of Patient or Personal Representative*
Printed Name of Eps on the Go II Provider*
Employee Job Title*
Signature of Provider*
Date*

MonthDayYear
Time*

Minutes

AM/PM Option
EPS ON THE GO II LLC: CONFIRMATION OF SERVICES

Revised August 2024
Location Details At Time Of Submission:
Should be Empty:

CONFIRMATION OF SERVICES