Telehealth Platform Technical Issue Report

Telehealth Platform Technical Issue Report — Form Fields

This healthcare template includes 9 fields. Allow patients or clinicians to report technical difficulties encountered during a telehealth visit. Free to customize and use on ZenBuild.

• Your Name (text, required)
• Email Address (email, required)
• Reporter Role (multiple choice, required) — options: Patient, Clinician, Administrative staff
• Date of Issue (text, required)
• Scheduled Appointment Time (text, required)
• Type of Issue (dropdown selection, required) — options: Audio problem, Video problem, Connection dropped, Unable to join session, Login or access issue, Recording error, Other
• Describe the issue in detail (long text, required)
• Device and Browser/App Used (text, optional)
• Was the appointment able to proceed? (multiple choice, required) — options: Yes - fully, Yes - partially, No