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Consent to Baseline Lab Service

First Name: {{patient_first_name}} Last Name: {{patient_last_name}} Birthdate: {{patient_birthdate}}

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.

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, 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: In the alternative, you may pay us $225 now to cover all costs of processing and analysis. Nothing will be billed to insurance and no portion of this amount will be refunded to you.

☐ OPTION 1: ☐ OPTION 2:

Date: {{current_date}}

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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

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Baseline Lab Service (Brick-and-Mortar)

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2026-03-03 09:12:15 UTC

Document Baseline Lab Service (Brick-and-Mortar)
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2026-03-12 14:17:41 UTC

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