Protect Your Practice with Proper Telehealth Consent
Telemedicine Consent Form
Obtain legally compliant informed consent for virtual visits—covering technology, privacy, limitations, and patient rights before the first video call.
About This Template
Telehealth without proper consent is a liability time bomb. Patients assume virtual visits work exactly like in-person care, then complain when you can't examine a rash through a pixelated video feed. State medical boards require documented informed consent for telemedicine—specific disclosures about technology risks, privacy limitations, and when in-person care is necessary. One patient complaint about "not being told" can trigger a board investigation.
This template captures legally-required informed consent elements: technology requirements (device, camera, internet), understanding of telemedicine limitations (no physical exam, technology failures possible), privacy acknowledgments (encryption used, patient-side privacy their responsibility), emergency protocols (call 911, not us), and patient rights (can refuse, can request in-person). Required yes/no acknowledgments ensure patients confirm understanding of each element.
Every telehealth visit starts with documented consent meeting state requirements. Patients set appropriate expectations before their first virtual visit—no surprise complaints about what telemedicine can't do. Digital signatures with timestamps provide audit trail for compliance. Reduce liability exposure from uninformed patient complaints. Streamline virtual visit onboarding to under 5 minutes.
Key Features
- Informed consent
- Technology requirements
- Privacy acknowledgment
- Limitations disclosure
Use Cases
Multi-State Telehealth Practice
Your telehealth practice serves patients across 15 states, each with different informed consent requirements. Some states require specific disclosures about provider location, recording policies, or emergency protocols. Managing paper consent forms across jurisdictions is impossible.
Pain point: Different states have different consent requirements. Paper forms can't adapt to patient location. Compliance team spends hours ensuring each state's requirements are met.
Behavioral Health Virtual Visits
Your behavioral health practice offers virtual therapy sessions. Privacy is paramount—patients need to understand that their end of the video call might not be secure (roommate walks in, unsecured WiFi). You also need consent for session recording for supervision or quality assurance.
Pain point: Mental health patients have heightened privacy concerns. Must document that patient takes responsibility for their environment privacy. Recording consent required separately from general telemedicine consent.
Pediatric Telehealth
Your pediatric practice offers virtual visits for sick kids. Parents must consent on behalf of minors, but you also need to verify the consenting adult is the legal guardian. Technology requirements include having the child visible on camera, not just the parent.
Pain point: Consent for minors requires guardian verification. Parents sign on behalf of children, creating different consent flow. Must ensure child is present during visit, not just parent.
Specialist Telemedicine Consultations
Your specialist practice offers telemedicine consultations for patients referred from other providers. Patients need to understand that telemedicine may not replace the need for in-person specialist visits for procedures, imaging, or physical examination.
Pain point: Patients expect definitive diagnosis via video, but specialists often need in-person exam or tests. Consent must set expectations that virtual visit may result in recommendation for in-person follow-up.
Form Fields (23)
Patient Information
Patient Name
Date of Birth
Email Address
your@email.comPhone Number
(555) 123-4567Technology Confirmation
Do you have access to a computer, tablet, or smartphone with a camera and microphone?
Do you have a stable internet connection?
Preferred Video Platform
Select preferred video platform...Understanding of Telemedicine
I understand that telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care.
I understand that telemedicine may involve electronic communication of my personal medical information to other healthcare providers.
I understand that telemedicine has potential limitations including: technology failures, security breaches, and the inability to perform physical examinations.
I understand that in the event of a medical emergency, I should call 911 or go to the nearest emergency room rather than rely on telemedicine.
Patient Rights
I understand that I have the right to refuse or discontinue telemedicine services at any time.
I understand that I have the right to request an in-person visit in lieu of telemedicine.
I understand that while telemedicine sessions use encryption technology, I should still take precautions to ensure privacy on my end.
Consent
I consent to participate in telemedicine services as described above.
I consent to the recording of telemedicine sessions for quality assurance purposes. (Optional)
Patient Signature
Date
Customization Tips
Add State-Specific Disclosures
Use conditional logic based on patient state to show jurisdiction-specific disclosures. Some states require disclosure of provider location, others require specific emergency protocols.
Include Recording Consent Separately
If you record sessions for quality assurance or supervision, add separate consent checkbox that clearly distinguishes recording from general telemedicine consent.
Add Minor/Guardian Flow
When patient is under 18, show additional fields for guardian name, relationship, and attestation that guardian is legally authorized to consent.
Integrate with Telehealth Platform
Push consent status to telehealth platform (Doxy.me, Zoom Healthcare) so providers see consent confirmation before starting virtual visit.
Add Consent Expiration
Set consent validity period (1 year) and automatically prompt for re-consent when period expires. Some regulations require periodic re-consent.
Suggested Workflows
Block Visits Without Consent
Trigger: 24 hours before scheduled telehealth appointmentBefore telehealth appointment can begin, verify consent form is completed and signed. If consent is missing, automatically send consent form link and notify patient that visit cannot proceed without it.
Send Consent Copy to Patient
Trigger: On form submission with signatureAfter consent is signed, automatically email patient a PDF copy of their signed consent form for their records. Include summary of key points they acknowledged.
Document Consent in EMR
Trigger: On form submissionWhen consent is completed, automatically create documentation entry in EMR noting telemedicine consent obtained, date, and patient acknowledgments. Consent PDF attached to patient chart.
Request Consent Renewal
Trigger: Scheduled - 11 months after consent dateIf consent policy requires annual renewal, automatically email patient 30 days before consent expires with link to complete new consent form.
Developer Notes
Schema Highlights
Boolean acknowledgment fields create clear audit trail—patient explicitly confirmed each required disclosure
Signature field with timestamp provides legally defensible documentation
Consent date separate from signature date allows tracking when consent was given vs. when form was completed
Integration Hints
Telehealth platform API integration to verify consent status before visit start
EMR integration to attach consent PDF to patient chart
DocuSign/HelloSign API for enhanced signature verification if required
MongoDB Considerations
Index on {patientId: 1, signatureDate: -1} for quick consent status lookup
Store consent version to track which disclosures patient agreed to
TTL index not recommended—consent records should be retained per medical records retention requirements
Consider compound index on {patientState: 1, consentDate: 1} for jurisdiction-specific compliance queries
Tags
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Complexity
Form Type
Est. Completion
~6 min
Total Fields
23
Category
Healthcare & Wellness