Telehealth Consent Form
A telehealth consent form has to say what remote care can't do. No examination, limited diagnostics, and a plan for what happens when the connection drops mid-consultation.
For clinics, practices and healthcare providers.
Consent to the limitations, not just the format
Patients understand a video call. What they often don't understand is that a clinician cannot palpate an abdomen, look in an ear, or take a blood pressure through a screen - so a remote consultation sometimes ends in "you need to be seen", which feels like a wasted appointment if nobody said so in advance.
So this template states the limitations plainly and asks the patient to acknowledge them, along with the technology-failure plan and where they'll be sitting. That last one matters: a consultation from a car park is not private, and the patient should choose that knowingly.
Say what they're agreeing to, in plain words
A consent form that nobody reads protects nobody. The statements in this template are short, specific and separate - so ticking one is a real decision rather than a formality.
Edit the wording to match what you actually do. It should sound like your practice, not like a legal template.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Digital, dated, and searchable
Every response is stored with the date and time it was submitted, and the whole set exports as a spreadsheet. Finding one person's answers takes seconds rather than a filing cabinet.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Full name
- Date of birth
- Email address
- Phone number
- Which country and region will you be in?
- I understand the limitations of a remote consultation
- I understand I may still need to be seen in person
- I understand the connection may fail, and that we will continue by telephone if it does
- Where will you take the call?
- I understand I should be somewhere private, and I'm responsible for my own surroundings
- May we record the consultation for your medical record?
- Someone else will be with me during the consultation
- I understand this is not an emergency service
- I consent to a consultation by video or telephone
More Healthcare forms
Questions
Do we need consent for every telehealth appointment?
Usually once, with a verbal confirmation at each consultation - but requirements vary by jurisdiction and payer. Check your own rules; some require consent to be documented per episode.
Can we record consultations?
Only with explicit consent, which this template asks for separately. Don't bundle it into general consent - recording is a distinct decision with distinct consequences.
Is this legal advice?
No. The wording is a practical starting point, not a legal document - have your own adviser check anything you rely on, especially where health, minors or money are involved.
Is a tick box a valid signature?
In many places a clear, dated, affirmative action is accepted, but it depends on your jurisdiction and what you're doing. If you need a drawn signature, print the response and sign it, or take the form as the pre-appointment record.
Can I keep a copy for the person who filled it in?
Yes - they see a confirmation on screen, and you can turn on an email so a copy of each submission lands in your inbox for your records.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your telehealth consent form today
Start from this template and change anything you like. Free to begin.