Consent to Telehealth Service

(Telehealth)

Date: {{current_date}}

Member Information

• **Member First Name: {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Member Last Name: {{patient_first_name}} {{patient_last_name}}** {{patient_input}}
• **Date of Birth: {{patient_birthdate}}** {{patient_input}}

Financial Relationship Disclosure

BSMM, LLC has a financial relationship with the entity that employs or contracts with your Provider. You are free to obtain your medical examination from another healthcare provider that is not associated with the Ennu platform. Ennu will use its pharmacy partner to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team. You must pay the full amount of the costs associated with use of the Service, including any prescriptions that are not covered by insurance.

Consent to Telehealth Services

☐ I consent to receive telehealth services as described above.

Signatures

Member Signature: {{patient_input}} Date: {{current_date}}

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Ted Ennenbach
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Lynn Scott
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Lynn Scott
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Lynn Scott
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Signature Certificate

Consent to Telehealth Service

Unique Document ID: 32995ef7f9bad737a41d6482de8048ad50598d79

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EnnuLife Patient Docs

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

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Lynn Scott

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

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Ted Ennenbach

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

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Timestamp	Audit
2026-03-03 09:12:15 UTC	Document Consent to Telehealth Service Uploaded by EnnuLife - docs-admin-ennulife@ennulife.com IP: 0.0.0.0
2026-03-09 12:25:00 UTC	Document viewed IP:

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