About this template
A telehealth permission form is an essential digital document used by medical practices, clinics, and mental health professionals to secure informed consent from patients before conducting virtual appointments. Obtaining clear, documented agreement ensures that patients understand the nature, risks, and benefits of telemedicine before treatment begins.
Using Doc2Form, healthcare providers can instantly convert policies and terms into a ready-to-use Google Form, making it effortless to collect patient authorizations online. This template standardizes the consent collection process, ensuring patients acknowledge virtual care terms, privacy policies, and communication methods from any device before their session starts.
Ideal for physicians, therapists, and virtual care clinics, this form eliminates administrative friction while maintaining clear records for your practice. Customize the terms and questions to fit your specific clinical workflow, branding, and state requirements in seconds.
Key features
- Collect informed consent securely before virtual appointments
- Streamline remote onboarding for telehealth patients
- Confirm patient agreement to virtual care terms and privacy policies
- Access responses instantly in Google Drive and Sheets
- Fully customizable to match your clinic's specific practice guidelines
Use cases
- Initial virtual consultations and intake sessions
- Ongoing telepsychiatry and mental health therapy appointments
- Remote specialist evaluations and follow-up reviews
- Digital health clinics expanding access to remote patients
What this form collects
- Patient Full Name (Short answer)Enter your first and last name as it appears on your ID.
- Patient Date of Birth (Date)Enter your date of birth using MM/DD/YYYY format.
- Patient Email Address (Short answer)We will send a copy of your submitted responses and virtual meeting links here.
- Patient Phone Number (Short answer)Best number to reach you in case of technical difficulties during your call.
- Are you completing this form on behalf of someone else? (Multiple choice)Select yes if you are a parent, legal guardian, or designated healthcare proxy.
- Representative Name (If applicable) (Short answer)If you are completing this on behalf of the patient, enter your full name.
- Representative Relationship to Patient (Short answer)Specify your relationship to the patient (e.g., Parent, Spouse, Legal Guardian).
- Acknowledgment of Telehealth Risks and Benefits (Multiple choice)I understand that telehealth involves the delivery of healthcare services using interactive audio and video technology, and that potential risks include technical failures or privacy breaches.
- Consent for Treatment (Multiple choice)I hereby consent to participate in telehealth consultations with healthcare providers at this practice.
- Digital Signature / Acknowledgment (Short answer)Type your full legal name to serve as your electronic signature confirming your agreement to these terms.
- Date of Consent (Date)Today's date.
FAQ
What is a telehealth permission form?
A telehealth permission form is a digital document used to gather informed consent from patients before providing healthcare services remotely, outlining the terms of virtual care.
Why is informed consent necessary for virtual care?
It ensures patients understand how remote appointments work, the limits of technology, and their rights regarding electronic health communications.
Can I customize the terms and conditions in this template?
Yes. Once you load this template into Doc2Form or Google Forms, you can fully edit the text to match your practice's specific policies and state regulations.
How do patients sign the form?
Patients can type their full name and submit the digital form securely from their smartphone, tablet, or computer before their scheduled appointment.
Where are patient responses saved?
All submissions are automatically organized in a linked Google Sheet, giving your administrative team instant access to records.
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.