Consent to Baseline Lab Service

(Brick-and-Mortar)

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 Options

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, you may pay us $199 now to cover the professional medical analysis by your medical provider. 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: ☐ [To be completed based on available information]

Important Note

NOTE: If you purchased online, you will not be charged any additional fee for your baseline lab service until you visit our office (excluding No-Show fees).

Consent and 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.

2025.07.09

Form Complete