PLEASE SEND YOUR TIMESHEETS TO THE ATTENTION OF:

PAYROLL
Email: domesticalliedpayroll@medprostaffing.com
Fax: 844-631-0052
No Later Than NOON EACH MONDAY Eastern Standard Time

WEEK ENDING

HEALTHCARE
PROFESSIONAL

CLIENT NAME
START FINISH LESS MGR
DAY DATE TOTAL
TIME TIME MEAL INT
SUN
MON
REGULAR TUE
SCHEDULE
WED
THUR
FRI
SAT
TOTAL HOURS FOR THE WEEK
START FINISH LESS MGR
DAY DATE TOTAL
TIME TIME MEAL INT
SUN
MON
ON CALL TUE
HOURS
WED
THUR
FRI
SAT
SUB TOTAL - ON CALL HOURS
MINUS - CALL BACK HOURS Less:
TOTAL- ON CALL HOURS

START FINISH LESS MGR

DAY DATE TOTAL
TIME TIME MEAL INT
SUN
CALL MON
BACK TUE
HOURS
WED
THUR
FRI
SAT
TOTAL CALL-BACK HOURS
I certify that: i) the hours shown above represent my total hours for the week and that they were approved by an authorized representative of the
client, ii) I have reported any injury that occurred this week to a representative of MedPro, and iii) I have completed all necessary notes and
documentation as per client instructions.

MedPro healthcare professional signature X

I hereby confirm that: i) the hours recorded above were worked by the MedPro healthcare professional and are eligible to be billed under our
services agreement with MedPro, and ii) the MedPro healthcare professional has completed all necessary notes and documentation relating to their
work.

Authorized client signature X