About this template
When transitioning patients to telehealth or expanding virtual care offerings, securing proper authorization is both a legal and clinical necessity. This Video Consultation Informed Consent Form template allows medical clinics, therapists, and healthcare practitioners to gather clear, documented permission from patients prior to a virtual appointment.
The form outlines the scope, nature, and inherent limitations of video communications, as well as confidentiality policies and emergency protocols. Patients review these terms, acknowledge their understanding by providing initials at key sections, and submit their formal electronic signature and date before their session begins. Using Doc2Form, you can instantly turn this document into a ready-to-use Google Form, making it simple to embed in welcome emails or patient portals.
Collecting digital consent streamlines your practice intake workflow while ensuring patients are fully informed about the technology, privacy measures, and communication protocols used during virtual care. Maintain clear records and protect both your practice and your patients with a streamlined, digital-first consent process.
Key features
- Collect legally sound telehealth consent digitally before appointments
- Include mandatory initial fields for specific policy acknowledgments
- Capture electronic signatures and date stamps effortlessly
- Compatible across all devices for easy patient completion
- Instantly convert and deploy via Google Forms
Use cases
- Initial telehealth appointments and virtual therapy intake
- Remote medical evaluations and follow-up consultations
- Telepsychiatry and online behavioral health sessions
- Digital health platform onboarding
What this form collects
- Patient Full Name (Short answer)Enter your first and last name as it appears on your photo ID.
- Date of Birth (Date)Enter your date of birth for patient verification.
- Today's Date (Date)Select today's date.
- Nature of Telehealth Services (Short answer)Initial here to acknowledge you understand that video consultations involve the use of interactive audio and video technology for remote healthcare delivery.
- Risks and Limitations of Technology (Short answer)Initial here to acknowledge that video consultations may have technical limitations, such as connection drops or audio delays, and that in-person care may occasionally be recommended.
- Confidentiality and Privacy (Short answer)Initial here to confirm you understand that while reasonable security measures are used, you are also responsible for ensuring a private, secure location for your end of the call.
- Emergency Protocols (Short answer)Initial here to confirm you have provided your current physical location and understand that in an emergency, local emergency services may be contacted.
- Electronic Communication Status & Consent (Multiple choice)Do you voluntarily consent to participate in video consultations with your healthcare provider?
- Patient Electronic Signature (Short answer)Type your full legal name to serve as your electronic signature representing your agreement to this consent.
- Signature Date (Date)Confirm the date of your signature.
FAQ
What is a video consultation informed consent form?
It is a specialized agreement that informs patients about the risks, benefits, and technical limitations of receiving medical or mental health care via video calls, securing their formal agreement prior to treatment.
Why is telehealth consent necessary?
Documenting informed consent protects both the provider and the patient by ensuring the patient understands virtual care limitations, privacy safeguards, and emergency procedures.
Can patients sign this form on their mobile phones?
Yes. When deployed as a Google Form, patients can easily open, read, initial, and sign the form on smartphones, tablets, or desktop computers without installing extra software.
How do I customize the terms and policies?
You can easily edit the text sections to reflect your clinic's specific telehealth policies, state regulations, or platform requirements before sharing the link with your patients.
Can patients withdraw their consent later?
Yes, patients generally retain the right to withdraw consent for telehealth services at any time, reverting to in-person care options as appropriate for their treatment plan.
Get this form in your Google Drive
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