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Telehealth Consent Form Template

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PURPOSE: The purpose of the "Telehealth Consent Form" is to gain the patient's consent in order to participate in telehealth appointments.

RECORDS: Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.

TELEHEALTH INFORMATION: The medical information related to history, records and tests of the patient will be discussed during the telehealth appointment with video and audio.

ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment.

PATIENT RIGHTS: The patient can withdraw his/her consent at any time and can ask the questions related to telehealth appointments and technical requirements for telecommunication.

Patient's Name
Parent/Guardian Name
I understand that all the laws that are protecting my privacy of medical history or information are also applied to telehealth practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use Telehealth for my treatment and diagnosis.

Are you in the medical field and needing to accept consent forms on your website? If so, then you should check out the Telehealth Consent Form Template from WPForms.

This template is one of many consent forms that comes pre-made with all of the fields and agreements you’d need in a form like this.

What Goes Onto a Telehealth Consent Form Template?

Any good medical consent form should include informative language that explains the consent form to the user, along with a clearly displayed agreement area. And with the Telehealth Consent Form Template from WPForms, you get these important elements on the template, plus so much more.

Before inputting any of their information, the form user is met with a handful of explanations describing the details of use for this consent form. This is a standard part of most medical consent forms, and is something that you can keep, edit, or delete as you see fit.

Then, the form user enters the patient information. This portion of the form collects the patient’s name, date of birth, parent or guardian’s name (if applicable), email, phone number, and address. The form user also provides an emergency contact phone number.

Next, the form user consents to the use of the information on this form by checking a box. The language used on this part of the form is another standard aspect of a consent form. But, once again, you’re free to edit the verbiage here however you’d like.

Finally, the form user enters a digital signature and the date of their submission.

Get started with WPForms today to create and customize your own Telehealth Consent Form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.