Consent to Baseline Lab Service

(Brick-and-Mortar)

Date: {{current_date}}

Patient Information

• **First Name: {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Last Name: {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Birthdate:** {{patient_input}}

Lab Service Overview

Your evaluation begins with a comprehensive laboratory analysis of your blood. This service has two components, the professional medical analysis performed by your medical provider, and the blood draw/lab processing performed by our laboratory partner, LabCorp. Using the results of that analysis, we can formulate an individual treatment plan to help you achieve your goals.

Payment Options

To cover the cost of the lab testing, you have two options. Please select one of the following:

OPTION 1: ☐ If you want to use health insurance, you may pay us $199 now to cover the professional medical analysis by your medical provider. LabCorp will send a statement for blood draws and lab processing to your insurance company. You will be responsible to LabCorp for any balance due after insurance, including but not limited to applicable deductibles or copayments. If you want to contact your insurer in advance to verify coverage, your medical provider will provide you with coding information that the insurer may request.

OPTION 2: ☐ [To be completed based on available information]

Important Note

NOTE: If you purchased online, you will not be charged any additional fee for your baseline lab service until you visit our office (excluding No-Show fees).

Consent and Signature

Patient Signature: {{patient_input}} Date: {{patient_input}}

Medical Services provided by Primary Medical of KY, P.S.C., Elite Health Services, P.A., CO., Primary Medical of IN, P.C.

2025.07.09

Form Complete

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Ted Ennenbach
(Awaiting Signature)

Ted Ennenbach
(Awaiting Signature)

Ted Ennenbach
(Awaiting Signature)

Ted Ennenbach
(Awaiting Signature)

Lynn Scott
(Awaiting Signature)

Lynn Scott
(Awaiting Signature)

Lynn Scott
(Awaiting Signature)

Lynn Scott
(Awaiting Signature)

EnnuLife Patient Docs
(Awaiting Signature)

EnnuLife Patient Docs
(Awaiting Signature)

EnnuLife Patient Docs
(Awaiting Signature)

EnnuLife Patient Docs
(Awaiting Signature)

Signature Certificate

Baseline Lab Service (Brick-and-Mortar)

Unique Document ID: a86754315f1a1ec45bd705ea3aa282a73f444e9a

Build. Track. Sign Contracts.

EnnuLife Patient Docs

Party ID: 912778d3-c6da-470f-8c3c-b93a78d14947

Awaiting signature

Lynn Scott

Party ID: 9b317c7c-cb4c-47e2-b751-d35f95204d2d

Awaiting signature

Ted Ennenbach

Party ID: 53ef3992-70b1-4f77-87d7-c48bb41977d1

Awaiting signature

Timestamp	Audit
2026-03-03 09:12:15 UTC	Document Baseline Lab Service (Brick-and-Mortar) Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com IP: 0.0.0.0
2026-03-12 14:17:41 UTC	Document viewed IP:

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://ennulife.com/