Consent · free template

Telehealth Consent Form

Collects a patient's agreement to a remote video or phone visit, technology limits and emergency contact details.

A ready-to-use consent, waivers & releases form for any team that needs demonstrable permission: 13 questions, 2 pages, 3 conditional rules.

Questions: 13
Pages: 2
Layouts: classic · card
Conditional rules: 3
Typical time: 4 min

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Live preview and test console

This is the real form. Answer it to test the 3 conditional rules — nothing is sent or stored.

Page 1 of 2 — Before your visit

1 question is hidden by conditional logic right now — change an answer above to reveal it.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Telehealth Consent Form is built for any team that needs demonstrable permission who need to record who agreed to what, and when.

Any team that needs demonstrable permission working in consent, waivers & releases.
Teams who need to record who agreed to what, and when without writing code or paying for a custom build.
Anyone replacing consent claims you can't evidence months later with one structured record per enquiry.
Respondents are customers, patients and participants — the form asks them 13 questions across 2 screens.
Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of consent claims you can't evidence months later and turns each submission into a record your team can act on immediately.

8 questions are required, so submissions arrive complete instead of needing a follow-up email.
It collects a verified email address so replies and confirmations land.
It captures a phone number for urgent follow-up.
It records a signature you can keep as proof of agreement.
It pins the request to a specific date.
Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

1Press “Use this template” — a fresh copy of Telehealth Consent Form lands in your workspace, ready to edit.
2Rename or delete any question, and change what is required. Nothing here is fixed.
3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 3 conditional rules ship with it.

Features advanced show logic: if “Where will you be located during the appointment?” is Outside the clinic's home state or country, the form dynamically exposes “Please confirm your current city and state/region”. Otherwise that question never appears.
Features conditional hiding: if “Preferred visit type” is Phone call only, “Have you tested your camera and microphone?” is removed from the form and is never submitted.
Features advanced show logic: if “Do you have someone with you during the visit?” is Yes, the form dynamically exposes “Name of person present”. Otherwise that question never appears.
All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

This form records a patient's agreement to be seen remotely before a video or phone appointment goes ahead, and it is built to sit alongside a clinic's own consent wording rather than replace it. It opens with the patient's contact details and their preferred platform, then explains in plain terms what a remote visit can and cannot do — for instance, that some exams need to happen in person. A location field captures where the patient will be during the call, which matters for licensing and for knowing where to send help in an emergency, and an emergency contact section covers what happens if the call drops or something urgent comes up. A short technology-check question flags patients who may need a phone call instead of video. The consent statement itself is left as an editable block so a clinic can paste in language reviewed by its own compliance or legal team; this template only handles the structure and the signature capture, not the legal content. It is deliberately narrower than a full patient registration or HIPAA authorisation form — pair it with those for a first-time patient's complete file.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Before your visit

Patient namerequired
Email addressrequired
Phone number
Date of appointmentrequired
Preferred visit typerequired
Where will you be located during the appointment?required
Please confirm your current city and state/region

Page 2 — Consent & contacts

Have you tested your camera and microphone?
Do you have someone with you during the visit?
Name of person present
Emergency contact name and phone numberrequired
Agreementrequired
Patient or guardian signaturerequired

13 questions in total.

How the form changes as it's filled in

This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “Where will you be located during the appointment?”

Reveals questions
If “Where will you be located during the appointment?” is Outside the clinic's home state or country, the form reveals “Please confirm your current city and state/region”.

Driven by “Preferred visit type”

Hides questions
If “Preferred visit type” is Phone call only, the form hides “Have you tested your camera and microphone?”, so nobody answers questions that don't apply.

Driven by “Do you have someone with you during the visit?”

Reveals questions
If “Do you have someone with you during the visit?” is Yes, the form reveals “Name of person present”.

Set it up step by step

1
Keep your own consent wording separate
Use this form to gather logistics and a general acknowledgement, then attach your clinic's reviewed consent language rather than editing the legal wording here.
2
Ask location before the call, not during it
Knowing where a patient will be matters for licensing rules that vary by state or country — collect it up front so scheduling can flag issues early.
3
Route phone-only patients around the tech check
The logic rule already hides the camera question when someone picks phone-only; leave it that way so the form doesn't confuse them.
4
Store the signed copy with the visit record
Keep the completed form attached to the appointment file so anyone reviewing the visit later can see consent was captured.

Mistakes to avoid

Treating this template's consent statement as legal advice instead of having a compliance reviewer approve the final wording.
Not asking where the patient will be, which can create licensing problems for cross-state or cross-border visits.
Skipping the emergency contact field, leaving no plan if a call drops during a sensitive conversation.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

Have your own legal or compliance reviewer sign off on the consent statement before publishing this form, and confirm the emergency contact plan with your scheduling team.

Works in both layouts

Browse classic templates Browse card templates

Forms that overlap this one

These pages cover the same subject ground as the telehealth consent form, matched on the words people actually search for.

Privacy & compliance

This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.

Frequently asked questions

Does this form make my telehealth practice compliant?

No — it only structures the questions and signature capture. Pair it with your own reviewed consent language and confirm compliance requirements with your legal or clinical lead, the same way you would with the HIPAA Patient Consent Form.

How is this different from the Patient Registration Form?

Patient Registration Form gathers a new patient's full contact, insurance and basic medical details. This form is narrower and specific to remote-visit logistics and consent, meant to run alongside registration rather than replace it.

Can I use this for a one-off video consultation instead of an ongoing patient?

Yes, it works well as a standalone form linked from an Online Appointment Booking confirmation email for single-session consultations.

What if the patient is a minor?

Change the signature field to require a parent or guardian and add a relationship field — this template assumes an adult patient by default.

Is the Telehealth Consent Form template free to use?

Yes. You can preview and test Telehealth Consent Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Telehealth Consent Form template ask for?

It asks 13 questions across 2 pages, 8 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Telehealth Consent Form form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this consent, waivers & releases form work?

3 conditional rules ship with the template: Features advanced show logic: if “Where will you be located during the appointment?” is Outside the clinic's home state or country, the form dynamically exposes “Please confirm your current city and state/region”. Otherwise that question never appears. Features conditional hiding: if “Preferred visit type” is Phone call only, “Have you tested your camera and microphone?” is removed from the form and is never submitted. Features advanced show logic: if “Do you have someone with you during the visit?” is Yes, the form dynamically exposes “Name of person present”. Otherwise that question never appears. All rules are editable in the Logic tab.

Where do responses to the Telehealth Consent Form form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Telehealth Consent Form form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

Is the signature on this form legally usable?

The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.

More forms teams pair with the telehealth consent form.

Related categories

All Consent, Waivers & Releases templates