Telehealth Consent Form Template

A Telehealth Consent Form records that a patient understands how a remote visit works — its benefits, its limits, and its privacy considerations — and agrees to receive care by video or phone. Telemedicine providers, therapists, counselors, and clinics offering virtual appointments use one so there is a signed record that the patient consented to care delivered over a screen rather than in person. Typical fields include the patient and provider names, a plain-language statement about the risks and benefits of telehealth, a privacy acknowledgment, and a dated signature — plus a guardian section for minors.

The signature is the purpose of the document: virtual care has trade-offs a patient should acknowledge before the visit begins. This layout keeps the telehealth explanation readable, places a privacy acknowledgment checkbox above the signature, and adds a guardian row so a parent can consent for a child. To be clear, this is a general-purpose layout with the sections most telehealth consents need — not legal or medical advice. Have the appropriate professional, such as your practice's compliance lead or attorney, review the wording before you rely on it.

How teams use this form

A therapy practice sends the form through its portal before a first video session so the client's file shows informed consent to remote care. A primary-care clinic collects one before phone follow-ups. A counseling service uses it to confirm the patient understands that a video visit is not a substitute for emergency care and to record how their session data is protected. The common thread: the virtual visit does not start until consent is on file.

Customize the statement before signing

Open the Word (DOCX) download to describe your telehealth platform, name the risks specific to your specialty, and set out your privacy and recording practices. Add your clinic name and logo, note what happens if the connection drops, and adjust the guardian section if you only see adults. The fillable PDF suits signing on paper or on a device; keep the checkbox and signature block intact so the consent is complete.

Common mistakes to avoid

Do not skip the limits of remote care — patients should understand that a telehealth visit may not be appropriate for every condition and is never a substitute for emergency services. Do not omit the privacy acknowledgment; how session data is stored and protected matters. And for a patient under 18, do not accept their own signature — a parent or legal guardian completes the guardian section. Give the patient a copy for their records.

Example scenario

A parent books a video visit for their 10-year-old with a pediatric provider. Before the appointment, the parent reads the telehealth statement — including the note that a video call cannot replace an in-person exam for certain symptoms — ticks the privacy acknowledgment box, records their relationship to the child, and signs the guardian line with the date. The practice stores the signed consent in the chart before the visit connects.

Choosing PDF or Word

This page provides a printable fillable PDF and an editable Word (DOCX) file. Use the Word file when you need to describe your platform, edit the risk and privacy language, or drop the guardian section before sharing, and the PDF when the text is set and you just need to fill and sign. Both include the privacy acknowledgment checkbox and a dated signature block so the consent is ready before the visit.