Telehealth Technology Check Form

Telehealth Technology Check Form — Form Fields

This healthcare template includes 9 fields. Pre-appointment technology check form for telehealth visits to ensure patients have the necessary equipment and connectivity. Helps reduce no-shows and technical issues during virtual appointments. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Email Address (email, required)
• Appointment Date & Time (text, required)
• Device You Will Use (dropdown selection, required) — options: Smartphone, Tablet, Laptop, Desktop Computer
• Does your device have a working camera? (multiple choice, required) — options: Yes, No, Not sure
• Does your device have a working microphone? (multiple choice, required) — options: Yes, No, Not sure
• Internet Connection Type (dropdown selection, required) — options: Wi-Fi (home or office), Cellular data (4G/5G), Wired / Ethernet, Public Wi-Fi
• Have you used video calling before (Zoom, FaceTime, etc.)? (multiple choice, required) — options: Yes, frequently, A few times, Never
• Any Technical Concerns? (long text, optional)