About this template
This Electronic Communication Consent Form template is designed for healthcare providers and professional services to securely obtain informed consent from patients or clients. It outlines the risks associated with electronic communication—such as email, text messaging, and patient portals—ensuring that your practice maintains transparency and clear communication boundaries.
By using this template, you can easily collect patient acknowledgments regarding data security, privacy, and preferred communication channels. It is an essential tool for any organization that prioritizes patient safety and needs a reliable, digital way to document consent before sharing sensitive information electronically.
Key features
- Clearly outlines risks of electronic communication
- Collects explicit consent for email and SMS
- Includes fields for patient identification and signature
- Easy to share via email or website link
- Mobile-friendly for quick patient completion
Use cases
- Private medical and dental practices
- Mental health and counseling clinics
- Telehealth service providers
- Specialized therapy and wellness centers
What this form collects
- Patient Full Name (Short answer)Please enter your full legal name.
- Date of Birth (Date)Required to verify your identity.
- Consent for Email Communication (Multiple choice)I understand the risks of email and consent to receive communications via this channel.
- Consent for Text Message Communication (Multiple choice)I understand that text messages may not be encrypted and consent to receive them.
- Consent for Appointment Notifications (Multiple choice)I agree to receive automated appointment reminders via my preferred contact method.
- Are you signing on behalf of another person? (Multiple choice)Select 'No' if you are the patient.
- Relationship to Patient (Short answer)If you are signing on behalf of the patient, please state your relationship (e.g., Parent, Legal Guardian).
- Electronic Signature (Short answer)By typing your full name here, you acknowledge that this serves as your legal electronic signature.
- Date of Signature (Date)Today's date.
FAQ
Why is this form necessary?
It ensures that patients are fully aware of the security risks associated with digital communication, protecting both the patient's privacy and the provider's liability.
Can I add my own terms and conditions?
Yes, you can easily edit the form description or add sections to include your specific clinic policies and privacy terms.
Is this form mobile-friendly?
Absolutely. Google Forms are responsive by default, allowing patients to read and sign the document from any smartphone, tablet, or computer.
How do I store the signed forms?
All responses are automatically saved to a connected Google Sheet, providing you with a centralized, searchable database of all patient consents.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.