Dr. Thomas Lodi, MD, MD(H) 

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Dr. Thomas Lodi, MD, MD(H) 

Group Consultation & Release Consent

Welcome, welcome! We are so glad that you have made the decision to join Dr. Lodi and a few others in a Group Consultation. It is our goal that your experience is enjoyable, informative, and impactful.

We need your help with a few important items:

  • Please review, sign and date the attached Group Participation & Release Consent. NOTE: If we do not have this form returned prior to your scheduled consultation, we will need to reschedule you for another date | time. 
  • Upload any and all applicable medical records for Dr. Lodi to review prior to the scheduled consultation time. This information will provide Dr. Lodi with a thorough understanding of your condition. To clarify, while the medical records are extremely beneficial, they are not required for your participation in the Group Consultation.

If you have any questions pertaining to the above items, please do not hesitate to reach out to hello@drlodi.com for further assistance & direction on next steps.

Group Participation and Release Consent Letter.

    The undersigned (the “Participant”) has requested to join in one or more group sessions with Thomas Lodi, MD, MD(H), {“Dr Lodi”}.

    The Participant acknowledges, understands, and agrees that by participating in Group Sessions (which may be held in person and virtually, and by written or email communications), private and personal data, which would otherwise by law or other regulation be considered and treated as confidential, will be necessity be openly discussed and shared with all other participants of such Group Sessions. The Participant further acknowledges that participation in the Group Sessions is completely voluntary and is not required by the Dr Lodi. To this end, the Participant hereby waives any legal or statutory or other rights of privacy or confidentiality, including (without limitation) in respect of his/her medical history, illness, treatments, and prognosis.

    The Participant hereby acknowledges, understands, and agrees that Dr Lodi (i) shall not be liable to the Participant, or his heirs or successors, or any other third party for making disclosures, and (ii) has no control over the further dissemination of such information once disclosed at a Group Session.

    If the Participant ceases to participate in the Group Sessions, he/she may withdraw this consent letter on seven (7) days prior written notice but acknowledges that it shall only be effective as to future disclosure by Dr Lodi and have no effect for any disclosures or discussions up to the effective date of termination.

    By Signing below, the Participant acknowledges that he/she is of the age of majority, and has read, understood, and agreed to the above release of confidential, personal, and private information during and related to the Group Sessions and shall have no claim against the Dr Lodi in this respect.

    Ask Dr. Lodi

    Every Sunday, Dr. Lodi goes live on Instagram and Facebook to answer your general health questions.⁠ Simply fill out the form below and Dr. Lodi will do his best to make time next Sunday to answer your question! Be sure to follow @drthomaslodi on Facebook and Instagram for updates!⁠

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