Telehealth Consent Form Template
A telehealth consent form for patients to share visit location and emergency contact details, confirm they understand video-visit limits, and consent to care by video.
When to use it
- Before a patient's first video appointment
- When a clinic starts offering telehealth visits
- When updating a patient's emergency contact or visit-location details
- Before a remote visit where the care team needs an emergency plan
What it asks
- Your full name
- Your email address
- Your phone number
- Where will you be physically located during the visit?
- Emergency contact name
- Emergency contact phone number
- How is this person related to you?
- I understand that the care team may use my visit location and contact my emergency contact or local emergency services if an emergency arises.
- I understand the risks and limitations of telehealth, including possible interruptions or privacy concerns.
- I have a device, internet connection, and a private place suitable for a video visit, or I will tell the care team if I need help with access.
- I consent to receive care by video visit and understand I may ask questions or withdraw my consent.
Why it should be encrypted
Visit location, phone numbers, emergency contact details, and consent choices are private. They should be readable only by the patient and the care team members who need them—not SealForm or unauthorized people.
Tips
- Explain how patients can ask questions or withdraw consent before they submit the form.
- Tell patients to enter the location where they will be during the visit.
- Customize the emergency instructions to match your care team's process.