Informed Consent Agreement

Informed Consent Agreement

* This document has been secured with a HIPAA-compliant asymmetric encryption algorithm to guarantee the confidentiality of your health information.

*Please do not use Firefox web browser as you will not be able to SAVE if you need to.*

Make sure you see the "Thank You" - page after submitting the form. If you don't check that you have filled out all required fields.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Informed Consent Agreement


1. Program Nature and Participation

I understand and agree that I am undertaking involvement in a wellness educational program by phone, internet videoconference or in person. I understand that what I will be receiving will be educational information as to the evidence-based, natural approaches to brain health or other health conditions, as well as potentially the Ayurvedic approach to health, which is a unique system based on the concepts of balance, doshas and overall tissue health to enliven and balance the healing intelligence of the body. I understand that unless and until I have a direct, in-person consultation with Dr. Lonsdorf, or telemedicine consultation while I’m present in a state in which she is licensed (IA, CA, FL, NY, NC, KS), I will not be participating in a medical consultation nor become Dr. Lonsdorf's patient nor have a patient-physician relationship with Dr. Lonsdorf. Until I consult in person or telemedicine as above, Dr. Lonsdorf will be unable to write prescriptions for me and unable to order tests for diagnostic purposes.*

2. Complementary Nature of Services

I also understand that the Ayurvedic or other health knowledge I receive in any consultations with Dr. Lonsdorf, including such information as I may receive during an in-person visit as a patient of Dr. Lonsdorf, is complementary only and is NOT a substitute for modern medical evaluation, diagnosis or treatment nor is it a substitute for conventional preventive testing (such as blood tests, Pap smears, mammograms, colon cancer screening and any other appropriate screening tests). I understand that the educational health information I will receive is also NOT for the purpose of diagnosing or treating any disease that I may have. For the treatment of any diagnosed disease that I may have, I agree to continue under the care of my family doctor and continue to seek the advice of any specialists with whom I have consulted, in addition to any services Dr. Lonsdorf may provide.*

3. Wellness or Ayurveda-Only Consultations

In the case that I am having a wellness, Ayurveda-only consultation, I understand that generally I will not be provided with any lab orders, though Dr. Lonsdorf may provide a suggested list to request of my local doctor. Any lab test orders provided to me by Dr. Lonsdorf are for overall wellness assessment purposes only. I understand such tests are not for the purpose of preventing, diagnosing or treating a disease, and only for my personal education regarding my wellness. I understand that in such a wellness, Ayurveda-only consultation, by executing this order for a lab test, I am not entering into a patient-doctor relationship with Dr. Nancy Lonsdorf. If any abnormal test results are found, I agree to notify my local doctor and request his or her professional advice as to how it should be addressed medically.*

4. Medical Treatment Modifications

I agree not to modify or suspend any medical treatment program that I am now receiving, based on the information I receive. I understand that if I have a specific medical condition, I am advised to review all options, approaches and treatment modifications discussed in this session with my personal physician before implementing them in my health program.*

5. Disclosure of Health Information

I understand that it is very important that I provide information that is as accurate and complete as possible. If I am aware of or have been advised by any physician that I am suffering from any disease or disorder, I agree that I will disclose this information to the physician in writing in this questionnaire. I also agree to disclose any medication or treatments that I am currently receiving.*

6. Responsibility for Advice

I understand that the Maharishi Ayurveda programs have been developed in part by Ayurvedic scholars associated with universities or other institutions. However, I recognize and agree that any advice or recommendations to me are the sole responsibility of Dr. Nancy Lonsdorf and no other person or organization.*

7. Nature of Herbal and Wellness Recommendations

I understand that any herbal food supplements recommended for me are not drugs and do not treat any disease. Any other programs recommended also do not treat any disease, but are alternative approaches which are for the purpose of specifically balancing the doshas, or underlying intelligence of the physiology, for the purpose of creating balance in the physiology and improving overall mental and physical well-being.*

8. FDA Statement

I understand that any herbal food supplements and other treatments and recommendations that I may be recommended have not been evaluated by the Food and Drug Administration nor are these approved by the FDA for the prevention, diagnosis, treatment or cure of any disease condition.*

9. Individual Reactions and Assumption of Risk

I understand that while the recommendations of the wellness and Ayurveda program are usually free of harmful side-effects, I am aware that individuals can react differently to diet, spices, herbs and lifestyle changes. I understand that I am advised to consult my personal physician before implementing them or changing my diet. If I use them I am electing to adopt these suggestions at my own risk. I further understand that such suggestions and treatments are not medically necessary for my condition, and that the physician's liability insurance may not cover adverse outcomes that may occur with these treatments.*

10. Privacy Policy

I affirm that I am hereby notified of the downloadable Practice’s Privacy Policy in pdf form, which is located along with the Practice Brochure on Dr. Lonsdorf’s website at http://ayurveda-ayurvedic.org/before-your-appointment/. I understand that I may additionally request a printed version of this Privacy Policy, which will be handed or mailed to me.*

11. AI Support Tool

To help ensure your visit is recorded accurately, a secure, HIPAA-compliant and anonymous AI tool will be used to create the visit notes and an organized list of your recommendations. Your identity will not be linked to the recording, and it will only be used for documentation of your care. By signing below, you consent to this supportive process which aids Dr. Lonsdorf in providing you the best care and attention possible.*

12. Telemedicine Consent

I understand that my healthcare may be provided through telemedicine, which uses a secure, HIPAA-compliant electronic platform to connect me with Dr. Lonsdorf at a different location. I acknowledge that telemedicine has benefits, such as convenience and access to care, as well as limitations, including the lack of in-person examination and possible technical issues. I understand that my medical information will be kept confidential as required by law, and I may stop telemedicine services at any time and request in-person care when available. By signing below, I give my consent to receive care by telemedicine.*

13. Paper Records Policy

Our practice is now paperless; if you do wish to send us paper records, a $30 fee applies for processing and scanning them into your secure chart, as well as returning the originals to you by mail with signature receipt, which maintains our paperless practice and allows you to keep them for future use. By signing below, you indicate that you understand and agree to this policy.*

14. Secure Email Messaging

Our practice now uses a secure, HIPAA-compliant, encrypted email service that integrates seamlessly with our current email provider at healthoffice@drlonsdorf.com. Messages you receive from us will look like any email but should have a green icon on the bottom left with the words “Secured by Paubox – HITRUST certified.” Any email you send to us by “reply” using one of the emails you received from us will also be secure and encrypted, including any attachments you include. This is a safe and convenient way for us to message each other and contributes to faster replies and turnaround. By signing below, you indicate that you understand and agree to this means of communication.*

15. Fees and Billing Policies

I agree to pay at the time of booking or time of service, as described in the Fee Schedule, all fees that I incur, or which are incurred on my behalf. I understand that such fees may change without notice; however, any agreed-upon package or program that I have started will be honored through its duration as stated in the materials I received. I have read the current fee schedule provided to me and agree to all terms, including cancellation and refund policies, overtime fees, and fees for email responses beyond those included in the program.

Billing for Additional Minutes:
I understand and agree to pay the hourly rate, as quoted in my confirmation email, for any additional consultation minutes that accrue beyond the time originally scheduled and already paid for, for my one-time visit or, if part of a consultation package, the actual consultation time in addition to that allotted for as described in the flyer I received.

I understand I will be informed by email after the consultation regarding the total of any additional minutes and the amount of any additional charge to my credit card, which I hereby authorize to be charged automatically.

Billing for Doctor Services Outside of the 2-Week “After” Window:
Included in your consultation or package fee are all responses to questions you send us in the 2-week period after you receive your visit recommendations. After 2 weeks, short answers that take the doctor less than 5 minutes to answer and do not require her to research into your medical chart materials are also included.

Billable responses that require the doctor to review your medical chart, including past history, past recommendations, supplement lists, lab test results, etc., are billed at $35/5-minute intervals (a common, even standard, practice in private, integrative practices today due to the volume of such questions received and the considerable doctor time that is needed for each such thoughtful and thorough reply).*

16. 72-Hour Cancellation Notice Requirement

I understand that NKL, MD PC requires 72-hours notice for a cancelled appointment. If I fail to give notice (i.e. “no show”) or give less than 72-hour notice regarding a cancellation, I agree to pay NKL, MD PC the current late cancellation fee for each cancelled and/or rescheduled consultation.*

17. Refund Policy

Note that for all patient visits, only 50% of the consultation fee or program package fee is refundable once the doctor has begun reviewing your submitted materials (questionnaires, lab results, etc.) in preparation for your visit and in order to write lab orders (or her curated list of recommended labs). This review usually takes place approximately 4 weeks prior to your scheduled appointment. This policy is due to the extensive preparation time and effort the doctor invests in this pre-visit review, including any in-depth research she may do and for writing the relevant lab orders.*

18. Medicare Non-Acceptance

I understand that NKL MD, PC has opted out of Medicare, and I agree that I will not submit any claims to Medicare in any circumstances. This prohibition applies even in the case that a secondary insurer may require claims first be submitted to Medicare before they will cover any services that Medicare will not.*

19. Limitation of Liability

I recognize that no claims or guarantees have been made to me regarding specific medical benefits or improvement in my medical condition(s) that I will receive as a result of any wellness and Ayurveda educational information I may receive. I understand and agree that, notwithstanding anything to the contrary in this agreement, the limit of liability of Dr. Lonsdorf for any services provided to me, including Ayurveda educational services or physician-patient services, shall not exceed five times the amount paid to Dr. Lonsdorf by me for such services. This agreement shall be governed by the internal laws of the state of Iowa and not its conflict of laws principles.*

20. Zoom Communications

While Zoom communications are encrypted and the platform is HIPAA-compliant and secure, because it is an internet-based platform, no guarantee can be made that it is secure from third-party “hackers.” While Dr. Lonsdorf and her staff take reasonable precautions with the information under their control, interception or misuse of client communications over Zoom is highly unlikely but theoretically possible. I, the client, agree to assume the risk and accept the consequences of such breaches, or alternatively, to request a telephone consultation if I do not wish to incur these risks.*

21. Legal and Litigation Limitation

I understand that no medical or health issues will be addressed that involve an ongoing or contemplated lawsuit. I agree not to bring such medical issues for evaluation or treatment by Dr. Lonsdorf.*

22. Open Payments Disclosure

I have been informed that “The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.”*

Final Notice

This agreement is intended to have legal significance.

NOTE: Click the “Submit” button below to submit it.

AFTER SUBMITTING, if you see the Thank You page with the lotus flower, your form will be encrypted and saved and the doctor can access it.

If after submitting you remain on this page, then be sure to scroll up and complete the required questions you may have missed. These will be highlighted in red.

IF YOU HAVE PROBLEMS, PLEASE CONTACT US AT 641-469-3174.

Name
Clear Signature

Nancy K. Lonsdorf, MD
Copyright © 2026 All Rights Reserved
Cookie Policy Privacy Policy Terms of Service Disclaimer Privacy Policy PDF