Telehealth consent form template
A telehealth consent form explains what changes when care moves to a screen: the provider can't examine you in person, the connection can fail, and in an emergency you need help near you, not an hour away. It also records where the patient will be, which matters for licensing. Read this template below, then open it in SignMaster and send it before the first virtual visit.
Updated November 5, 2026 · 3 min read
The contract
Gray blanks are yours to fill in before you send. Each signer fills in the blanks in their color.
- You, before sending
- Patient
- Provider
Telehealth Informed Consent
I, Patient name, born Date of birth (the "Patient"), agree to receive care by telehealth from Provider name and credentials of Practice name (the "Practice"), on the terms below.
1. What telehealth is
Telehealth means care delivered at a distance: live video, a phone call, secure messages, or photos and readings the Patient sends in, instead of a visit in person. The Practice offers these services by telehealth: Services offered by telehealth.
2. Benefits and limits
Telehealth can save travel and waiting time and make care easier to fit around work or family. But the provider can't touch, listen to or closely examine the Patient, so some problems are harder to assess. The provider may decide that a visit in person, a test or a referral is needed, and a telehealth visit may end early for that reason.
3. Technology and privacy
- Visits use Video or phone platform, which the Practice has chosen to protect privacy. No connection over the internet can be guaranteed completely secure.
- The Patient will join from a private place, on their own device rather than a shared or work one where possible, and will tell the provider if anyone else is in the room.
- The provider will also be in a private place, and nobody else will join without the Patient's agreement.
- Neither the Patient nor the provider will record a visit without the other's written consent.
4. Identity and location
At the start of each visit, the Patient will confirm who they are and the address where they are at that moment. Licensing rules usually depend on where the patient is located, and the provider is licensed in States where licensed. If the Patient is somewhere else during a visit, it may have to be rescheduled.
5. Emergencies
Telehealth is not for emergencies. In an emergency, the Patient will call 911 or go to the nearest emergency room. If a medical or safety emergency happens during a visit, the provider may call emergency services to the Patient's location and contact this person: Emergency contact.
6. If the connection fails
If a video visit drops, the provider will try to reconnect for up to Minutes to reconnect minutes and then call the Patient at the number below. If the visit can't be finished, it will be rescheduled, and the Patient won't be charged for the part that was lost.
7. Fees and insurance
A telehealth visit costs Telehealth visit fee unless insurance pays a different amount. Coverage of telehealth differs between plans, so the Patient will check theirs and is responsible for any amount it doesn't pay. The Practice's usual cancellation and missed-visit policy applies.
8. Prescriptions and records
The provider prescribes only when it is safe to do so by telehealth, and some medicines can be prescribed only after an in-person exam under federal or state rules. Telehealth visits are documented in the Patient's record just like in-person visits, and the Patient has the same rights to see that record.
9. Your choices
The Patient may ask for an in-person visit instead of telehealth, where the Practice offers one, and may withdraw this consent at any time by telling the Practice in writing. Withdrawing won't affect the Patient's right to future care.
Patient contact details
Phone for call-backs: Patient phone Email: Patient email
Usual address when joining visits: Usual visit address
I have read this consent, including the limits of telehealth and what to do in an emergency, my questions have been answered, and I agree to receive care by telehealth.
Patient (or parent or legal representative)
Provider
Opens it in SignMaster as a template you can edit and send.
A starting point, not legal advice. Have a lawyer review it for your state and situation.
On this page
Why telehealth needs its own consent
Your regular consent to treatment assumes the patient is in the room. Telehealth adds questions it doesn't answer: what if the video drops mid-session, who joins the call, whether it's recorded, and what happens if the patient is in crisis three states away. Many states require providers to get and document a patient's consent to telehealth, and the rules differ by state and by profession. The Center for Connected Health Policy tracks them state by state.
Sign it once before the first virtual visit, and keep it alongside the patient's general consent and intake forms.
What the template covers
- What telehealth is, and which of your services you offer that way.
- Benefits and limits, including that some visits will need to switch to in person.
- Technology and privacy: your platform, the patient's private space, others in the room, and no recording without consent.
- Identity and location: confirmed at each visit, with the states where the provider is licensed.
- Emergencies: 911 first, and a named contact if something happens on camera.
- Dropped connections: how long you'll try to reconnect, the call-back number, and no charge for a lost visit.
- Fees, insurance, prescriptions and records, and the right to choose in-person care or withdraw consent.
Mistakes to avoid
- Not asking where the patient is. Licensing generally follows the patient's location, and in an emergency you need an address. Ask at the start of every visit, not just on the form.
- No plan for dropped calls. Patients wait, then give up. Say how long you'll try to reconnect and which number you'll call.
- Treating telehealth as a promise. Some conditions need hands-on care; the form should say you may move the visit in person.
- Leaving out other people in the room. A partner listening in changes what a patient will say. Ask, and write it in.
About health information
Telehealth providers are often HIPAA covered entities. SignMaster doesn't claim HIPAA compliance, so check with your compliance adviser before using it for clinical records. This form collects consent and contact details; keep visit notes in your clinical records system.
How to send it with SignMaster
- 1
Open the template
Choose Use this template. The patient signs first and the provider second.
- 2
Fill in the practice details
Add the provider's name and credentials, the services you offer virtually, your platform, the states where you're licensed, the reconnect time and the fee in the gray blanks.
- 3
Send it with the visit link
Enter the patient's name and email and set a sign-by date before the first appointment. They fill in the blue blanks, emergency contact, phone and usual address, and sign from any phone or computer, with no account.
- 4
Add an access code if you want one
Require a one-time code SignMaster emails to the patient before the form opens, so only they can open it. See require an access code to sign.
- 5
Countersign before the visit
Sign as the provider. Both of you get the signed PDF with a certificate of completion showing who signed, when and from which IP address.
One envelope with the intake forms
Most practices send the telehealth consent alongside an intake or treatment consent. Add both templates to one envelope; roles with the same name merge, so the patient fills in everything in one sitting. Patients who prefer Spanish, Portuguese, French, Vietnamese or Chinese can switch the signing page language, while the form text stays in English.
Questions? Answers.
Is a telehealth consent form required?
Often, yes. Many states require informed consent for telehealth, some specifically in writing, and certain payers have their own rules. Check your state's requirements and your profession's board.
How often does the patient need to sign it?
Usually once, and again if your terms change or your state requires a periodic renewal. Confirm identity and location verbally at the start of every visit.
Can a patient sign the form on their phone?
Yes. The link opens on any phone or computer, and electronic signatures are valid for most consents under federal and state law. See can you e-sign a medical consent form.
Does it work for therapy sessions by video?
Yes. Pair it with a counseling informed consent, which covers confidentiality and crisis planning in more depth.