Consent to Telehealth Baseline Lab Service

(Telehealth)

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 Agreement

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.

Consent

I AGREE ☐

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.

2025.04.23

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Baseline Lab Service (Telehealth)

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Timestamp	Audit
2026-03-03 09:12:15 EDT	Baseline Lab Service (Telehealth) Uploaded by EnnuLife Patient Docs - docs-admin-ennulife@ennulife.com IP 24.238.5.27

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