About this template
The Telehealth Consent Form is an essential tool for healthcare providers transitioning to or expanding their virtual care services. This template allows you to clearly outline the nature of telehealth services, potential risks, and patient rights, ensuring that your patients are fully informed before their appointment begins. By moving your consent process to a digital format, you eliminate the need for physical paperwork and ensure that every patient has reviewed and signed off on your practice's policies prior to their session.
This Doc2Form template is designed to be professional, clear, and easy for patients to navigate from any device. It captures critical information including patient identity, explicit agreement to the terms of service, and a digital signature. Using this form helps streamline your administrative workflow, allowing you to focus on providing high-quality care rather than managing paper records. Simply customize the terms and conditions to reflect your specific practice requirements and share the link with your patients via email or your patient portal.
Key features
- Clear sections for outlining virtual care terms and risks.
- Mobile-friendly design for easy patient access.
- Captures explicit patient consent and digital signatures.
- Reduces administrative overhead for virtual practices.
- Easily customizable to fit specific clinic policies.
Use cases
- Initial intake for new virtual therapy patients.
- Annual consent renewal for ongoing telehealth clients.
- Specialist consultations conducted via video conference.
- Remote follow-up appointments requiring updated consent.
What this form collects
- Patient Full Name (Short answer)Please enter your legal first and last name.
- Date of Birth (Date)Enter your date of birth (MM/DD/YYYY).
- Understanding of Telehealth (Multiple choice)I understand that telehealth involves the delivery of healthcare services using electronic communications and that I have the right to withhold or withdraw consent at any time.
- Technical Requirements (Multiple choice)I acknowledge that I am responsible for providing a private, secure, and stable internet connection for my telehealth session.
- Emergency Protocol (Multiple choice)I understand that in the event of a medical emergency, I should disconnect from the telehealth session and call emergency services (911) immediately.
- Patient Signature (Short answer)By typing your full name here, you are providing your electronic signature and confirming that you have read and understood the terms above.
- Date of Signing (Date)Enter today's date.
FAQ
What is the purpose of a telehealth consent form?
It ensures patients understand the nature, limitations, and risks of receiving medical care remotely, while providing legal documentation of their agreement to proceed.
Can I customize the terms and conditions in this template?
Yes. Once you load this template into your Google account, you can edit the text to include your specific practice policies, state-mandated disclosures, or unique service agreements.
How do I collect signatures on this form?
The form includes a dedicated field for the patient to type their name as a formal acknowledgement, which serves as a digital signature for your records.
Is this form suitable for mental health professionals?
Absolutely. It is widely used by therapists, counselors, and psychologists to establish boundaries and informed consent for remote sessions.
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.