About this template
A Telehealth Waiver Form is an essential digital document used by medical professionals, clinics, and mental health practitioners to secure informed consent and liability acknowledgment before conducting virtual appointments. This form ensures that patients understand the nature, risks, and benefits of remote healthcare services while establishing a clear administrative record for the provider.
Our template is designed to streamline the intake process by gathering patient demographics, physician details, emergency contact information, and explicit acknowledgment of telehealth policies. It features structured fields for names, dates of birth, contact details, and formal consent statements. Providers can easily distribute this template via a simple link, allowing patients to review and sign off on terms from any device before their consultation begins.
Using Doc2Form to generate this form into your Google Drive allows you to maintain clean, organized records of patient consent without relying on clunky paperwork. It reduces administrative friction, ensures your remote practice remains structured, and gives patients a transparent, easy-to-complete onboarding experience.
Key features
- Collect remote care consent and liability acknowledgments effortlessly
- Capture complete patient and physician contact details
- Include clear terms of service and virtual consultation policies
- Record official signing dates and confirmation timestamps
- Organize all patient responses neatly in a connected spreadsheet
Use cases
- Initial virtual consultations and telemedicine check-ups
- Online mental health therapy and counseling sessions
- Remote specialist evaluations and follow-up appointments
- Digital health clinic patient onboarding workflows
What this form collects
- Patient Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Patient Email Address (Short answer)Where we can send appointment links and follow-up documents.
- Patient Phone Number (Short answer)Include area code (e.g., 555-0199).
- Physician Full Name (Short answer)Name of the doctor or healthcare provider conducting the session.
- Physician Title or Specialty (Short answer)E.g., MD, Licensed Professional Counselor, Family Physician.
- Acknowledgment of Telehealth Terms (Multiple choice)By selecting 'I Agree', you acknowledge that you understand the risks, benefits, and limitations of receiving healthcare services via telecommunications.
- Patient Signature Acknowledgment (Short answer)Please type your full legal name as confirmation that you agree to all terms above.
- Date of Patient Signature (Date)Select today's date.
FAQ
What is a telehealth waiver form?
A telehealth waiver form is a digital document used to inform patients about the nature of virtual care and obtain their formal consent and liability agreement before a remote appointment.
Why is a telehealth consent form necessary?
It ensures patients understand the limitations and technical requirements of remote care, protects the practice by clarifying liability, and documents that informed consent was given.
Can I customize the waiver terms in this template?
Yes. Once the template is generated in your Google account, you can edit the text, add specific clinic policies, or adjust questions to fit your exact practice requirements.
How do patients sign the form remotely?
Patients complete the form online from their phone, tablet, or computer, submitting their text-based agreement and signing details directly through Google Forms.
Where are the form submissions stored?
All responses are automatically collected in a secure Google Sheet linked to your form, allowing you to easily review and reference patient agreements.
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.