Ability and Empowerment Services Abilityempowermenths Patient Visit Record · secured in accordance with HIPAA
Getting your location…
1

Patient

2

Reason for Visit

3

The Meeting

Where did the meeting take place? *

How long did it last? *

The meeting is timed as ending the moment this record is signed.

4

Photo Together

One photo of the patient and the staff member together, taken at the meeting.

5

Patient Signature

The patient signs below
Sign here with your finger

By signing, the patient attests to the accuracy of the information provided

6

Staff Signature

The staff member signs below
Sign here with your finger

The staff member attests to having met this patient in person

7

Consent

Personal data is processed in accordance with our privacy policy and applicable regulations. It will never be shared with third parties without explicit consent.
Ability and Empowerment Services · 1 N Charles St, Baltimore, MD 21201 · (443) 438-5538

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