El Jestic Home Health Services: Client Service Agreement
This agreement outlines the terms and conditions for in-home care services provided by Eljestic Home Care.
Client Full Name
*
First Name
Last Name
Client Address
*
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email Address
*
example@example.com
Representative Full Name (if applicable)
*
First Name
Last Name
Representative Address (if applicable)
*
Representative Phone Number (if applicable)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Representative Email Address (if applicable)
*
example@example.com
Purpose of Agreement
*
Scope of Services (Detailed from Care Plan)
*
Services Included in Care Plan
*
Personal Care (e.g., bathing, dressing)
Medication Reminders
Meal Preparation
Mobility Assistance
Companionship
Other
Service Hours Per Week
*
Client Responsibilities
*
Hourly Rate (BBD)
*
Billing Cycle
*
Please Select
Weekly
Bi-Weekly
Monthly
Late Payment Fee (BBD)
*
Confidentiality and Privacy Agreement
*
Termination of Agreement (Terms by Parties)
*
Termination of Agreement (Terms by Provider)
*
Dispute Resolution and Governing Law
*
I agree to the terms and conditions outlined in this agreement.
*
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Representative Signature (if applicable)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Eljestic Home Care Representative Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Agreement
Submit Agreement
Should be Empty: