Telehealth Appointment Consent Form Template

Ensure patients are informed, consented, and prepared before every virtual visit. This telehealth consent form captures the appointment type, reason for visit, current medications, and formal informed consent — everything your practice needs to document compliance and prepare a high-quality virtual care encounter.

Use this template

Last updated 21 August 2026

Fields in this template

Patient Full Namerequired
Date of Birthrequired
Email Addressrequired
Phone Numberrequired
Provider Name
Type of Telehealth Appointmentrequired
Video visit · Phone (audio-only) visit · Asynchronous (secure message) visit
Preferred Appointment Date
Reason for Visit / Current Concernsrequired
Current Medications or Relevant Health Concerns
Do you have access to reliable internet or phone service for this appointment?required
Yes, I have reliable internet access · I will use my phone/cellular connection · I may have connection issues — please advise
Consent to Telehealth Servicesrequired
I consent to receiving healthcare services via telehealth, understanding that my provider will not be physically present
Understanding of Telehealth Limitationsrequired
I understand that telehealth has limitations compared to in-person care and that my provider may refer me for an in-person visit if necessary

Who uses this template

Telehealth-first practicesHospital system virtual care programsPrimary care practices offering virtual visitsMental health telehealth providersSpecialist telehealth consultantsUrgent virtual care platformsConcierge telehealth servicesRural health telehealth programs

About this template

Telehealth consent is not just a legal formality — it is a clinical and ethical obligation. Before delivering care via video or phone, providers must ensure patients understand what telehealth can and cannot do, that the visit is voluntary, and that they have the right to switch to in-person care. Collecting this consent digitally before the appointment — rather than verbally at the start of the call — creates a documented record and saves appointment time for clinical care.

This template combines consent collection with pre-visit preparation. The reason for visit and current medications fields give providers a clinical brief before they join the call, much like a nurse's pre-visit assessment in an in-person setting. The technical readiness question proactively identifies patients who may need to switch to a phone visit, preventing the frustrating last-minute scramble when video technology fails.

formformform makes it simple to incorporate this form into your telehealth scheduling workflow. Send the link automatically when a virtual appointment is confirmed. Patients complete it at home — taking time to think through their symptoms rather than rushing through it at the start of a call. You receive a notification with their responses, your provider reviews it before joining, and the visit begins with clinical context already established.

14 form ideas you can build with this template

Primary Care Video Visit Consent

Used before routine primary care video appointments for established patients managing chronic conditions or seeking preventive care.

Telepsychiatry Appointment Consent Form

Captures informed consent for remote psychiatric evaluation or medication management with additional disclosures about emergency protocol.

Telehealth Mental Health Therapy Consent

Used by therapists offering video sessions to document consent and gather presenting concerns before the first virtual therapy appointment.

Urgent Care Virtual Visit Consent

Streamlined version for same-day urgent virtual care with focus on current symptoms, onset, and severity rather than full medical history.

Specialist Telehealth Referral Consent

Documents consent for a specialist teleconsultation requested by a primary care provider, including the reason for referral.

Pediatric Telehealth Parental Consent Form

Collects parent or guardian consent for a child's virtual visit, with fields for the child's age, symptoms, and caregiver contact.

Rural Health Telehealth Consent Form

Addresses connectivity challenges specific to rural patients, including satellite internet variability and phone-only visit fallback.

Employer Telehealth Benefit Consent Form

Used by employer-sponsored virtual care programs to document employee consent and collect insurance or benefit plan information.

Post-Operative Telehealth Follow-Up Consent

Collects consent for virtual post-surgical check-ins with wound description, pain level, and medication tolerance questions.

Physical Therapy Telehealth (Tele-PT) Consent

Documents consent for remote physical therapy evaluation, noting the patient's home environment and available exercise equipment.

Nutrition and Dietitian Virtual Consultation Consent

Used before telehealth nutrition counseling sessions to gather consent, dietary goals, and current eating patterns.

Dermatology Asynchronous Teledermatology Consent

Covers consent for store-and-forward teledermatology where the patient submits photos for async provider review rather than a live video visit.

School-Based Telehealth Student Consent

Collects parental consent for telehealth services delivered to students through a school health program during the school day.

Home Health Telehealth Monitoring Consent

Used by home health agencies to document consent for remote patient monitoring and virtual check-in visits between in-home care visits.

What's included

Explicit informed consent checkboxes satisfy regulatory documentation requirements

Appointment type selection for video, audio-only, or asynchronous visits

Technical readiness check prevents failed appointments

Reason for visit field gives providers context before joining the call

Provider name field for multi-provider practices

Current medications field for clinical preparation

Fully customizable to match your state's telehealth consent requirements

How to create a telehealth appointment consent form

1
Click "Use this template" to load the telehealth consent form into the formformform builder.
2
Customize the consent language in the checkbox fields to match your state's telehealth informed consent requirements — these vary by jurisdiction.
3
Add your practice name and logo by editing the heading and adding a paragraph with contact information.
4
Configure email notifications to deliver the pre-visit summary to the treating provider before the appointment time.
5
Add the form link to your appointment confirmation emails and scheduling confirmation texts.
6
Publish the form and consider embedding it on your patient portal or website virtual visit page.

Best practices for your telehealth appointment consent form

Customize consent language for your state

telehealth consent requirements differ by state and payer. Review your jurisdiction's requirements and update the checkbox language accordingly.

Send it with the appointment confirmation, not the day of

patients who receive the form too close to their appointment time feel rushed. 24 hours ahead is ideal.

Keep the pre-visit clinical questions focused

ask about current medications and reason for visit, but leave detailed history for the appointment itself. Overloading the pre-visit form causes abandonment.

Address the technology gap proactively

the 'reliable internet' question catches potential tech failures before they disrupt care. Have a backup phone number protocol ready for patients who flag connection concerns.

Use the reason for visit field clinically, not just administratively

providers who read the patient's own description of their concern before joining the call report better rapport and more efficient visits.

Store completed consent forms for your compliance records

export submissions regularly or use the dashboard to maintain a log of consented telehealth encounters.

Frequently asked questions

Is a digital telehealth consent form legally valid?

In most US states, digital consent collected via an online form satisfies telehealth informed consent requirements when the patient explicitly agrees via a checkbox or electronic signature. Always verify your specific state's telehealth regulations and payer requirements.

Can I add an electronic signature field to this form?

Currently formformform forms use checkbox-based consent, which is valid for most telehealth consent use cases. If your compliance requirements specifically require a drawn or typed signature, note this and plan accordingly.

How do I customize the consent language?

Click on either consent checkbox field in the editor and update the option text to match your practice's specific telehealth consent language, including your state's required disclosures.

Can I use this form for mental health telehealth appointments?

Yes, and for mental health telehealth you may want to add additional consent elements — for example, consent to the specific therapy modality, emergency protocols for the patient's location, and limitations of telehealth for crisis situations.

Does this form work for international telehealth?

The form itself works globally. International telehealth consent requirements vary significantly by country — you'll need to update the consent language to meet the regulatory requirements of your patient's jurisdiction.

How do providers access the pre-visit information before joining the call?

Providers receive an email notification with the full form submission when the patient submits. They can also review all submissions in the formformform dashboard before logging on to the telehealth platform.