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Return Visit Profile Update

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 *

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  • (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!)
  • *Please Note: We strictly maintain the privacy of your email address.

  • Emergency Contact

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  • Informed Consent Agreement

  • Download Practice’s Privacy Policy.

  • IMPORTANT - READ THIS BEFORE HITTING SUBMIT:

    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. End up at the start of this form again? Then scroll down to the red print that shows where you’ll need to make corrections. Make the corrections, hit “Submit” again and be sure you get to the flower — otherwise repeat the correction process until you get the Flower! Thank you.

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

Nancy K. Lonsdorf, MD
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