Telehealth Consent · Popular

Virtual Medical Visit Telehealth Informed Consent Form

Obtain patient consent for telehealth services quickly and securely. Covers HIPAA privacy, risks, benefits, and patient rights in one easy-to-use form.

Use This Template Free Preview

Espresso theme

formbuilder.ai/f/virtual-medical-visit-telehealth-informed-consent-form

Patient Full Name

· · ·

Date of Birth

· · ·

Email Address

· · ·

Submit

The Virtual Medical Visit Telehealth Informed Consent Form is a comprehensive digital form designed to help healthcare providers collect legally compliant patient consent before conducting remote medical consultations. It captures essential patient information, insurance details, and emergency contacts while clearly communicating how telehealth services work, including the use of electronic communications, live audio/video, and digital health records.

This template is ideal for clinics, private practices, hospitals, and telehealth platforms that need to document patient acknowledgment of the risks, benefits, and limitations of virtual care. It covers critical topics such as technology failure risks, privacy protections under HIPAA, the patient's right to withdraw consent, and guidance on emergency situations — ensuring both providers and patients are fully informed before the visit begins.

Using this ready-made consent form saves administrative time, reduces liability, and ensures a consistent, professional patient experience. Fully customizable to match your practice's branding and policies, it can be completed online before the appointment, streamlining your telehealth workflow from day one.

3 Pages

23 Questions

~8min To complete

Free No credit card needed

Field types singlecheckbox ×8 Short Text ×5 Date ×2 Phone ×2 Full Name Email Address Yes / No termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Patient Information 9 questions

Patient Information

1 Patient Full Name * Full Name

2 Date of Birth * Date

3 Email Address * Email

4 Phone Number * Phone

5 Home Address * Address

6 Emergency Contact Name * Short Text

7 Emergency Contact Phone Number * Phone

8 Primary Care Physician Name Short Text

9 Insurance Provider & Policy Number Short Text

Page 2 Telehealth Consent & Acknowledgments 7 questions

Understanding Telehealth Services

Telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. This may include consultation, diagnosis, treatment, education, care management, and self-management of a patient's condition. The information shared during your telehealth visit may include medical records, medical images, live audio/video, and output data from medical devices and sound/video files.

Risks & Benefits Acknowledgment

Benefits of telehealth include improved access to care, convenience, and reduced travel time. Potential risks include technology failures, interruptions in service, unauthorized access to transmitted information despite reasonable security measures, and limitations in the provider's ability to perform a physical examination. In rare cases, the provider may determine that telehealth is not appropriate and an in-person visit may be required.

1 I understand that telehealth services are not a replacement for emergency care. If I experience a medical emergency, I will call 911 or go to the nearest emergency room. * singlecheckbox

2 I understand that there are potential risks to using technology, including interruptions, unauthorized access, and technical difficulties, and that either I or my provider may discontinue the telehealth visit if the connection is inadequate. * singlecheckbox

3 I understand that my healthcare provider may determine that telehealth is not appropriate for my condition and may recommend an in-person visit instead. * singlecheckbox

4 I understand that I have the right to withhold or withdraw my consent to telehealth services at any time without affecting my right to future care or treatment. * singlecheckbox

Privacy & Confidentiality

5 I understand that my telehealth visit will be conducted in a manner consistent with applicable privacy laws (including HIPAA) and that reasonable steps will be taken to ensure the confidentiality of my information. * singlecheckbox

6 I agree to be in a private location during my telehealth appointment and understand that I am responsible for the security of my own device and internet connection. * singlecheckbox

7 Do you consent to the recording of your telehealth session for medical record purposes, if deemed necessary by your provider? * Yes / No

Page 3 Final Consent & Signature 7 questions

Consent Confirmation

By signing below, I acknowledge that I have read and understand the information provided regarding telehealth services. I have had the opportunity to ask questions, and I voluntarily consent to participate in a telehealth visit with my healthcare provider. I understand that this consent will remain in effect for all future telehealth visits unless I revoke it in writing.

1 I confirm that I am the patient (or the legal guardian of the patient) and that all information provided is accurate to the best of my knowledge. * singlecheckbox

2 I voluntarily consent to receive healthcare services via telehealth and agree to the terms outlined in this form. * singlecheckbox

3 I have read, understood, and agree to the Telehealth Informed Consent terms and conditions as described above. * termsandconditions

4 Date of Consent * Date

5 Patient Signature (or Legal Guardian Signature) * Signature

6 Printed Name of Person Signing * Short Text

7 Relationship to Patient (if signing as guardian) Short Text

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.