Telemedicine Consent Form Template
Ensure proper informed consent for virtual healthcare visits with a comprehensive telemedicine consent form that addresses technology risks and virtual care limitations.
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What is a Telemedicine Consent Form?
A telemedicine consent form documents patient understanding and agreement to receive healthcare services via video, phone, or secure messaging. It ensures patients understand the benefits and limitations of virtual care compared to in-person visits.
Informed consent for telemedicine requires patients to acknowledge potential technical limitations, privacy considerations, and situations where in-person care may be necessary. This protects both the patient and provider by establishing clear expectations.
Legal telemedicine consent forms vary by state and jurisdiction. Our template provides core elements common to most healthcare settings - adapt based on your state's requirements and your organization's specific technology and practices.
Key Features
Technology Risk Disclosure
Clear explanation of technical limitations and potential connectivity issues
Informed Consent Checkboxes
Patient acknowledgment of virtual care limitations and appropriate use cases
Privacy & Security Confirmation
Agreement to use secure platform and acknowledgment of privacy practices
Emergency Contact Requirements
Ensures patient location and emergency contact info for safety
Electronic Signature
Digital consent signature documenting patient agreement
Jurisdiction & State Compliance
Customizable language for state-specific telemedicine regulations
Why Use This Template?
Legal Protection
Documented informed consent protects providers against liability claims
Clear Patient Expectations
Patients understand when telemedicine is appropriate vs. requiring in-person care
Privacy Assurance
Confirms patients understand privacy practices for virtual healthcare
Regulatory Compliance
Meets state and federal telemedicine consent requirements
What's Included in This Template
Full Name & Date of Birth
textPatient identification for consent documentation
I understand telemedicine has technology limitations
checkboxConfirms awareness of potential technical issues or connection problems
I have suitable private location for visit
checkboxEnsures patient privacy and appropriate environment for telehealth
I understand emergency situations require in-person care
checkboxConfirms patient awareness of telemedicine limitations for emergencies
I consent to electronic signature
checkboxLegal requirement for electronic consent documentation
Emergency Contact Information
textRequired safety information for telemedicine visits
Electronic Signature
textDigital signature confirming informed consent
Perfect For
Telemedicine Platforms
Virtual health providers collecting informed consent before first video visit
Hybrid Medical Practices
Clinics offering both in-person and virtual visit options
Psychiatric Telehealth
Mental health providers documenting consent for remote psychiatric care
Remote Patient Monitoring
Providers collecting consent before monitoring patients remotely
Frequently Asked Questions
Is telemedicine consent required by law?
Yes - most states and jurisdictions require informed consent for telemedicine. Requirements vary by state regarding what must be disclosed. Check your state medical board's telemedicine requirements and customize this template to ensure compliance. Some states require specific language about technology risks, privacy, and when telemedicine is inappropriate.
Can patients refuse telemedicine and request in-person visits?
Yes - patients can refuse telemedicine, and providers must respect that choice. This form confirms the patient's informed decision to participate in telehealth, not that they must use it. Offer in-person visits as an alternative.
What should I disclose about privacy and security?
Clearly explain which platform you're using, whether the connection is encrypted, and any limitations (video recordings, family members in background, internet security risks). Confirm HIPAA compliance and any state-specific privacy requirements. Link to or attach your full privacy policy.
What if the internet connection fails during a visit?
Your consent form should address this: "If your internet connection is disrupted, we will attempt to reconnect. If unable to reconnect, we will resume your visit at a scheduled time or offer an in-person appointment." Confirm how you handle technical failures and rescheduling.
Can I use electronic signatures for legal telemedicine consent?
Yes - most states accept electronic signatures for telemedicine consent per the Uniform Electronic Transactions Act (UETA). However, a typed name or checkbox confirmation is usually sufficient. Check your state's specific requirements.
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