Return Visit: Profile Update

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

This form provides Dr. Lonsdorf with important updates on your health and lifestyle information and helps make your appointment as beneficial as possible.

Please fill out and submit the information requested below at least one day prior to your consultation.

Thank you!

* NOT FULLY COMPATIBLE WITH FIREFOX WEB BROWSER *

Step 1 of 4

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Home)
Phone (Work)
Phone (Cell) OLD—Do not remove
Phone (Cell)*

(Note: A cell phone number is required to set up and verify your electronic health record with us. Please enter your cell phone number, or, if you have none, one of someone close to you who will relay a confirmation code to you. This relay will usually occur sometime in the next 1-2 days as we set up your account. Thank you!)
Fax Number
Email*
*Please Note: We strictly maintain the privacy of your email address.
Age
Height
Weight
Blood Pressure, recent readings
Date of Blood Pressure reading above
Heart rate (beats per minute)
Date of Birth
Parents Name (if You Are Under 18)
Sex
- Male
- Female
Marital Status
- Married
- Single
- Divorced
- Widowed
Occupation
Emergency Contact
Relationship*
Do not have an emergency contact
- Do not have an emergency contact
Phone*
(###) ###-####
Name*
First Last
Do you have long-term care insurance (i.e. for nursing home, or other extended care facility)?
- Yes
- No

Return Visit Profile Update

Return Visit: Profile Update

Step 1 of 4

Emergency Contact

Informed Consent Agreement