Forms, consent and waiversForm
Telehealth consent form template
Get a patient's informed consent before the first video or phone appointment: how remote visits work, how their information is protected, what telehealth cannot do, what happens in an emergency or if the connection fails, and their right to choose in-person care.
Opens in the Salsox editor with 7 signing fields already placed for Provider and Patient. Add their emails and send. The free plan sends 3 documents a month.
Who signs
- Provider (you)
- Patient
Preview
Telehealth Consent
Practice: Willowbrook Family Clinic Patient: Olivia Chen Date of birth: 14 March 1988
1. What telehealth is
Telehealth means receiving care by video or phone instead of in person. Appointments take place using a secure video platform provided by the clinic, with a link sent before each appointment.
2. Limits of remote care
The clinician cannot physically examine me during a telehealth visit. They may decide that an in-person visit, a test or a referral is needed, and may end a telehealth visit if remote care is not appropriate.
3. Privacy
The practice uses a platform with encryption and protects my information as it does for in-person care. Sessions are not recorded without my separate written consent. I will join from a private place, and I understand there are some risks with any electronic communication, despite these protections.
4. Location and emergencies
At the start of each visit, I will confirm where I am, so that help can be sent if I need it. Telehealth is not for emergencies: in an emergency, I will call 911.
5. If the connection fails
If the video connection fails, the clinician will call me on the mobile number on your patient record. If we cannot reconnect, the appointment will be rescheduled.
6. My choices
Telehealth is voluntary. I may choose an in-person appointment instead, and I may withdraw this consent at any time, in writing, without it affecting my care.
7. Fees
Telehealth visits are billed in the same way as in-person visits, unless the practice tells me otherwise in advance. I am responsible for checking my insurance coverage.
Consent
I have read this form, had the chance to ask questions, and consent to receive care by telehealth.
Patient initials: Initials · Patient
Patient, or parent or guardian: Signature · Patient Date: Date · Patient Name: Name · Patient
Clinician: Signature · Provider Date: Date · Provider Name: Name · Provider
These templates are general starting points, not legal advice. Laws differ between countries and states: check that a template suits your situation, or ask a lawyer, before you rely on it.
About the Telehealth consent form template
Telehealth lets patients see a clinician by video or phone, but remote care has limits a patient should understand before agreeing to it. Many regulators and insurers expect a documented consent before the first telehealth appointment, and it is good practice everywhere.
This form explains how appointments happen and on which platform, how the practice protects privacy, and what telehealth cannot do, such as a hands-on examination. It sets what happens if the connection drops, asks the patient to confirm where they are during each visit so help can be sent in an emergency, and confirms they can choose an in-person appointment at any time.
Check the rules where the patient is located, not only where the clinician is: licensing, recording and consent requirements differ between states and countries. Add your platform's privacy terms if required.
- Signers
- 2
- Signing fields placed
- 7
- Details to fill in
- 6
How to use this template
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Used in
Questions
Is written consent required for telehealth?
In many places it is required or strongly expected, by law, by regulators or by insurers. A signed form is the clearest record.
Why ask where the patient is during the visit?
So the clinician can send emergency help to the right place, and because licensing rules depend on the patient's location.
Are telehealth appointments recorded?
Not under this form. Section 3 says sessions are not recorded without the patient's separate written consent.
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