Telehealth Consent Form

Telehealth Consent Form — Form Fields

This healthcare template includes 6 fields. Obtain patient consent for telehealth or virtual care appointments before the visit begins. Covers the limitations of remote care, privacy considerations, and technical requirements. Ensures compliance with telehealth regulations and patient rights. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Provider Name (text, required)
• Device You Will Use for the Appointment (dropdown selection, required) — options: Smartphone, Tablet, Desktop / Laptop computer, Unknown / Need assistance
• I understand and consent to the following (checkboxes, required) — options: Telehealth has limitations compared to in-person visits, My session may be conducted via video, audio, or messaging, I can withdraw consent and request an in-person visit at any time, My health information will be protected under HIPAA
• I consent to receive telehealth services (multiple choice, required) — options: Yes – I consent, No – I prefer an in-person appointment