Free Telehealth Consent Form Template

Gathering informed consent from patients can be time-consuming and fraught with complexity. This telehealth consent form template is designed for healthcare providers seeking to simplify the consent process, ensuring that patients understand their rights and responsibilities. You can effortlessly collect electronic signatures, customize the document for your specific practice, and maintain compliance with legal requirements. With clear terminology, user-friendly design, and accessibility features, this template helps you provide a seamless telehealth experience for your patients while protecting your practice. Start using the live template today.

When to use this form

Use this consent before a video or phone visit with a physician, therapist, or dietitian. It fits new patients, annual renewals, and minors with a guardian. If the remote visit is part of a larger intake, you can bundle it with the Patient admission and consent form. For high-risk care plans, pair it with an Emergency permission form so you can act fast if a crisis occurs. If your payer needs pre-approval for virtual services, your staff can attach a Medicare prior authorization form. The outcome: clear expectations, documented permission, fewer delays, and better compliance on visit day.

Must Ask Telehealth Consent Questions

Do you consent to receive care by telehealth and understand the benefits, risks, and alternatives?
This secures informed consent and makes clear that a video or phone visit is not a full physical exam. If someone declines remote care, documenting that choice with an Against medical advice form protects both you and the patient.
What is your current physical location and who should we contact in an emergency?
Location is required each session so clinicians can route local help if a crisis occurs. An emergency contact supports safety planning for issues like suicidality, severe reactions, or domestic violence.
Are you in a private space, and do you agree to use a secure device and network during the visit?
This protects confidentiality and reduces the risk of eavesdropping or data leaks. It prompts patients to move rooms, use headphones, or pause if others enter.
Do you authorize us to share necessary information for treatment, payment, and operations, including with your insurer or pharmacy?
This enables coordination of care and billing and sets expectations about copays and benefits. For Medicare or managed care, your team may also request prior authorization to avoid claim denials.
What device will you use today, and do you consent to enable camera, microphone, and any offered recording features?
Knowing the device, OS, and bandwidth helps support prepare and reduces connection issues. Recording, if available, is only enabled with explicit permission, and you may withdraw consent at any time.

More Forms

Question		Response
Legal full name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
Email address		[email protected]
Mobile phone number		555 555 5555
Current residential address		This is a test
If you are completing this on behalf of the patient, provide your full name (if applicable)		John Smith
Your relationship to the patient (if applicable)		This is a test
Are you the patient?		Yes
Emergency contact full name		John Smith
Emergency contact phone number		555 555 5555
Emergency contact relationship to patient		This is a test
I consent to receive healthcare services via telehealth.		1
I understand that telehealth uses electronic communications and may limit physical examination.		3
I understand the potential benefits and risks of telehealth, including possible technical failures, delays, or data security issues.		4
I understand that I can withdraw my consent to telehealth at any time before or during care.		1
I understand telehealth is not appropriate for emergencies; I will call local emergency services or go to the nearest emergency department when needed.		4
I will ensure I am in a private, safe, and stationary location (for example, not driving) during sessions.		4
I understand that my health information will be protected under applicable privacy laws and may be used or disclosed for treatment, payment, and healthcare operations.		3
I understand that fees may apply, my insurer may be billed, and I am responsible for charges not covered by my plan.		2
I have been informed of alternatives to telehealth and can choose in-person care when available.		3
Do you consent to audio or video recording of telehealth sessions if clinically appropriate?		Yes
Do you authorize the provider to share a visit summary with your primary care clinician?		Yes
Primary care clinician and clinic (if authorization given)		This is a test
Preferred contact method for follow-up		SMS/text
Best time window for contact (local time)		Afternoon
Your location during the telehealth session (state/province and country)		This is a test
Physical address where you will be during the session (for emergency purposes)		This is a test
Preferred pharmacy (name and address)		This is a test
I have read and understand this Telehealth Consent and agree to receive telehealth services.		No
Typed name of patient or legal representative (serves as signature)		This is a test
Date of signature		2025-10-15T00:00:00.000Z
If signer is not the patient, indicate your authority (for example, parent, legal guardian, power of attorney)		This is a test
I confirm the information provided is accurate to the best of my knowledge.		True

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Telehealth Consent Form Template

Easily Obtain Online Consent for Telehealth Services

When to use this form

Must Ask Telehealth Consent Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

Telehealth Consent Form Template

Easily Obtain Online Consent for Telehealth Services

When to use this form

Must Ask Telehealth Consent Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results