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Consent to Telehealth 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.

I agree to pay $225 to cover lab processing and analysis. Nothing will be billed to insurance and no portion of this amount will be refunded to you. I have also been made aware that I will have the option to utilize insurance for continuing lab draws beyond my baseline lab draw.

☐ I AGREE

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.
2025.04.23

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Baseline Lab Service (Telehealth)

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2026-03-03 09:12:15 EDT

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