A telehealth consent form records that a patient understands how a video or phone visit works, what it cannot do, and what happens if the connection fails or an emergency comes up. It is separate from consent to a specific treatment, and it should describe only the visit formats your clinic actually offers. Have your counsel and clinical lead approve the wording, because telehealth rules differ by state and by profession.
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A drafting aid, not medical or legal advice. Telehealth rules vary by state and by profession. Have your counsel and clinical lead approve the final wording before patients use it.
| Field | Type | Required | Why you ask it |
|---|---|---|---|
Patient name | Short text | Required | Ties the consent to a person and to the visit record. |
Date of birth | Date | Required | Helps the clinic confirm identity before a visit starts. |
Visit formats coveredVideo visitsPhone visits | Multiple choice | Required | Limits the consent to the formats your clinic actually offers. |
Where you will be during visitsA city and state may be enough for many visits. Tell us if you will be traveling. | Short text | Required | Clinicians may need to confirm which state rules apply, and an emergency response needs a known location. |
Emergency contact name | Short text | Required | Someone the clinic can contact if it cannot reach you during a visit. |
Emergency contact phone | Phone | Required | The number the clinic calls. Tell this person they are listed. |
Who else will be presentOnly meSomeone else will be presentI am not sure | Single choice | Required | Shows whether the clinician needs to plan for a third person hearing the visit. |
Names of anyone else presentOnly if someone else will be in the room or able to hear the visit. | Short text | Optional | Lets the clinician know who is in the room or within earshot before the visit discusses personal details. |
Recording the visitYour clinic's counsel decides what recording is allowed. I do not agree to any recordingI agree to recording only if the clinic asks first and I say yes | Single choice | Required | Recording rules differ by state, so this consent should not assume one answer for everyone. |
Backup plan if the connection failsI have a phone number to use if the video connection failsI can join from a device that works with the clinic's approved system | Multiple choice | Required | Sets a fallback before the visit starts, so a dropped connection is less likely to turn into a missed visit. |
Right to an in-person visitI understand I can ask for an in-person visit instead, at any time | Multiple choice | Required | Shows the patient knows the option exists. Confirm the wording with your clinical lead. |
A consent to the visit format does not cover treatment decisions the patient has not discussed. Those need their own explanation, and their own consent where your process requires it.
Recording and sharing are separate decisions, each with its own legal review. Do not bundle them into the visit format.
A telehealth consent should never suggest that a patient cannot seek emergency help. Put emergency instructions in plain words, not in a waiver.
A city and state may be enough for many visits. Collect only what the clinic needs to respond, and leave the rest out.
If the patient will be in a place where your clinician is not licensed to practice, follow your own rerouting process before the visit goes ahead as booked.
Allow for the hourly production run, which must finish before the creator is notified. Send the link well before the visit rather than on the day.
Store emergency contact details where clinicians can reach them during a visit, under your own process. Export only what a clinician needs, because a CSV export contains every answer.
If a patient withdraws consent in writing, stop telehealth visits as your policy requires and note the date. The form does not remove records held in other systems.
No. A telehealth consent covers how a visit happens: video or phone, its limits, the location and the emergency plan. A consent for treatment covers a specific care decision. Keep them separate, so a patient knows exactly what each one agrees to.
It does not have to be. Attain OS shares a form as an online link, and it has no PDF or Word version to save. Your approved wording belongs in your own document system, so check that the online version matches it.
Treat it as a starting point. Telehealth rules vary by state, by profession and by payer, so a template written for another clinic may not fit your visit formats or the places your patients are. Have your counsel and clinical lead check the text before you use it.
That decision belongs to your counsel and clinical lead. A checkbox records that a patient confirmed the statements, but it does not verify that they understood them. Any signed or recorded verbal consent needs its own approved process.
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