CARD AUTHORIZATION ON FILE AGREEMENT

MEMBER NAME: {{patient_first_name}} {{patient_last_name}} DOB: {{patient_birthdate}}

ACH Information

Account Holder Name:

Bank Routing Number: Bank Account Number:

REQUIRED PRIMARY PAYMENT CARD FOR MEMBERSHIP FEES

Card Issuer (Visa, Mastercard, etc.): Account Number:

Expiration Date: CVV Code:

Card Type ☐ Credit Card ☐ Debit Card ☐ FSA ☐ HSA

Billing Address & ZIP Code:

SECONDARY PAYMENT CARD FOR MEMBERSHIP FEES

Card Issuer (Visa, Mastercard, etc.): Account Number:

Expiration Date: CVV Code:

Card Type

☐ Credit Card ☐ Debit Card ☐ FSA ☐ HSA

Billing Address & ZIP Code:

ACCOUNT TO CHARGE FOR PRESCRIPTIONS & LAB TESTING (SELECT ONE):

☐ ACH ☐ Primary Card ☐ Secondary Card

If you choose not to use your insurance for any future services, such as continuing lab work and medications, you must inform us.

OPTION 1: I choose to use my insurance for future services, such as continuing lab work and medications. In the event that insurance does not cover these services, I agree to pay out of pocket for the difference.

OPTION 2: I choose not to use my insurance for future services such as continuing lab work and medications.

INITIALS:

I hereby authorize this Merchant (ennu, Concordia Practice Management, LLC, BSM Holdings, LLC, Body Shapes Medical Management, LLC and/or its assigns and third-party vendors, including New Vitalis Pharmacy), to keep my account information on file for payment and to initiate debit or charge entries on this account as amounts are owed for the Member Account listed above. I acknowledge that the transactions to my account must comply with U.S. law. I understand that a charge may be made to my credit card account periodically to pay for amounts owed, and this charge may come from the Merchant or any elected third-party health care provider. If my credit card information listed above changes for any reason, I will notify the Merchant immediately. This authorization shall remain in effect until the Merchant has received notice from me of its termination. In the event of a declined charge, my account may be charged a $25.00 service fee for each occurrence.

Date: {{current_date}}

Cardholder Signature

I acknowledge I have received a list of pre-negotiated pricing for various prescriptions, supplements and labs. I understand that these prices are subject to change over time. I further understand I will be responsible for these costs, or the balance of what insurance may not cover (the lesser of the two). I have been informed that New Vitalis LLC is affiliated with BSM Holdings, LLC and that I have the right to choose my pharmacy.

Initials:

BSMM Card Authorization Agreement 2025.04.16

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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

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

Adopt & Sign

Alex AssessmentTest
(Awaiting Signature)

(Awaiting Signature)

Michelle Clark
(Awaiting Signature)

Ted Ennenbach
(Awaiting Signature)

Lynn Scott
(Awaiting Signature)

EnnuLife Patient Docs
(Awaiting Signature)

Signature Certificate

Card Authorization on File Agreement

Unique Document ID: 5f38bcbde27f9449fd5b4581373ba67716bfaa85

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

Michelle Clark

Party ID: 11dd3bef-afec-4606-b3c4-4f5bcddac8b2

Awaiting signature

Party ID: f77b9040-fd92-435e-b963-8872205d5f9e

Awaiting signature

Alex AssessmentTest

Party ID: 6673d599-4b58-4710-8a47-9f5cb69caf4e

Awaiting signature

Timestamp

Audit

2026-03-03 09:12:15 UTC

Document Card Authorization on File Agreement
Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com
IP: 0.0.0.0