Fluent Forms Template Library

Telehealth Consent Form Template

Automate virtual care intake with this professional telehealth consent form.

Telehealth Consent Form

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Telehealth Consent Form (#18) (#684)

Patient Information

Emergency Contact & Location

Disclosures & Acknowledgments

 

Please review the following terms regarding your virtual care:

  • Nature of Telehealth: I understand that 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.
  • Benefits & Risks: Benefits include convenient access to care. Anticipated risks include potential technical interruptions, unauthorized access due to security failures, or the determination by the provider that virtual care is no longer appropriate for my condition.
  • Privacy & Security: I understand that the laws protecting the confidentiality of my medical information also apply to telehealth.
  • Right to Withdraw: 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.
  • Emergency Protocol: I agree that if I am experiencing a medical emergency during a session, I will call emergency services or proceed to the nearest emergency room. 

 

Consent & Authorization

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About this template...

This telehealth consent form helps healthcare providers, virtual clinics, and telemedicine platforms collect patient authorization for remote medical services in a legally compliant way. Whether you’re offering video consultations, remote diagnostics, or ongoing virtual care, this form captures all essential consent elements and ensures patients understand the nature, risks, and limitations of telehealth.

Patients provide their name, date of birth, email, phone, and current physical location for emergency response purposes. An emergency contact section collects backup contact details in case of urgent situations during virtual visits. The disclosures section outlines the nature of telehealth, benefits and risks, privacy protections, the right to withdraw consent, and emergency protocols, ensuring informed consent.

The consent and authorization section includes acknowledgment checkboxes confirming the patient has read the disclosures, understands risks and alternatives, and agrees to use a secure location and reliable internet connection. A digital signature field and date stamp provide legal documentation.

Telehealth Consent Form

Features of this Template

  • Collects patient name, date of birth, email, phone, and current physical location.
  • Emergency contact name and phone number for urgent situations.
  • Detailed disclosures covering nature of telehealth, benefits, risks, privacy, withdrawal rights, and emergency protocols.
  • Consent checkboxes confirming understanding, acknowledgment, and agreement to use secure connections.
  • Digital signature field and date stamp for legal compliance.
  • Easy to customize disclosures, consent language, and emergency protocols.
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