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Pre-Service Consultation Consent

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Thomas Lodi, MD, MD(H)

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In order to allow patients an opportunity to assess the potential benefits of engaging Dr. Thomas Lodi’s medical services, Dr. Lodi offers a telephone/internet consultation to discuss a potential patient’s symptoms and medical history, consideration of the nature of his approach and its fit with a patient’s needs. Any discussion of potential treatments is solely for this purpose, and is not offered as medical advice or recommendations. Medical diagnosis and treatment requires confirmation by proper diagnostic work-up through review of medical records, collection of additional labs and a face-to-face office visit. Follow-up requires a combination of occasional in-person and telephone/internet care. For patients who wish to pursue treatment but are unable to travel to meet with Dr. Lodi, a consultation with a patient’s treating physician may be possible. For patients who need on-going health coaching and are unable to meet with Dr. Lodi, non-medical support is available, please inquire about the terms of such assistance.

Telephone/internet communications do not establish a physician-patient relationship. Dr. Lodi is not responsible for care and no medical regimens should be started or discontinued as a result of a telephone/internet discussion with Dr. Lodi prior to a face-to-face visit.

Internet Communication: If consultation occurs over Skype, clients should understand that while its communications are encrypted, Skype is not considered a secure patient web portal. No guarantee can be made that the Skype service protects users’ data or the content of communications or that it is secure from third-party “hackers.” Further, e-mail is not a secure and confidential method of communicating health information. While Dr. Lodi will take reasonable precautions with the information under their control, interception or misuse of client communications over Skype, email, or telephone, while unlikely, are possible. Clients agree to assume the risk and accept the consequences of such breaches.

Confidentiality: This consulting is a confidential relationship. Dr. Lodi agrees to keep all information strictly confidential, except in those situations where such confidentiality would violate the law.

No Guarantees: No claims or guarantees are made with regard to coaching achieving any specific goals, objectives, benefits or improvements in life or health condition.+

Important Insurance Notice: Dr. Lodi’s pre-service consultations are not reimbursed by insurance, Medicare or any other third-party payor. Payment in full is required at each session. Clients agree not to submit claims for these services to any third-party for payment and are responsible for payment even if an effort is made to obtain reimbursement that is denied, whether because services are “non-covered” or “not medically necessary.”

Informed Consent for Pre-Service Consultation

I have read, understood and agree to the terms set forth in this consent form and hereby authorize a pre-service consultation. I understand that I do not become Dr. Lodi’s patient until I see him in person at his office. I agree that I will not make changes in my medical regimen based on our discussion until such time as I have been seen by Dr Lodi in person and become his patient. If I have a condition which requires medical care, I have or will consult my primary care physician or appropriate specialist. I understand that no recommendations are being made for me to discontinue or change any treatment provided by any other health care professional. It is important that I maintain regular visits with my primary care physician and medical specialists as appropriate. I have been adequately informed, and my questions have been satisfactorily answered. I represent that I do not represent a third party and sign this voluntarily.


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