A telehealth consent form, also called a virtual care consent form, records a patient’s agreement to care by video, phone, secure message, or email, after they’ve heard what it can and can’t do, how their privacy is protected, and what happens in an emergency. Copy the free form with a verbal consent script and a chart line, see a new patient’s first video visit and a therapy client moving to phone sessions, and check what goes in each part.
Blank telehealth consent form template
FreeTELEHEALTH CONSENT FORM Consent to virtual care by video, phone, or message [Practice name] [Address, phone, and website] THE PATIENT Name: [Full name] Date of birth: [Date] Home address: [Full street address] Callback number: [The number to call if a visit drops] Consent given by: [The patient, or a parent, guardian, or substitute decision-maker, with their name and relationship] Clinician: [Name, credentials, license or registration number, and where they join from] HOW WE WILL SEE YOU Mark each one you agree to. You can agree to some and not others. Video visits: [Yes or no] using [Name of the video platform] Phone visits: [Yes or no] Secure messages through [Portal name]: [Yes or no] for [Booking, results, refills, or short questions] Email or text: [Yes, no, or not offered] for [Reminders only, or the other uses you agree to] Replies: [Usual reply time, such as within 2 business days]. Messages are not read after hours. Never use them for anything urgent. WHAT VIRTUAL CARE CAN AND CAN'T DO Virtual care can save you a trip. It works well for many follow-ups, results, medication reviews, counseling, and some new problems. Your clinician can't touch or listen to your body, can't take most measurements, and sees only what the camera shows. Something an in-person exam would find could be missed. If you need to be seen in person, your clinician will tell you why and how soon, and help you book it: [Where in-person visits happen, and how to book one] WHERE YOU ARE AND AN EMERGENCY PLAN At the start of every visit, you will be asked where you are. Your clinician can see you only while you are somewhere they are allowed to practice, so tell them before a visit if you will be traveling. Emergency contact: [Name, relationship, and phone] If a visit drops: [What happens, such as the clinician calls your callback number within 5 minutes] If you become unwell during a visit, your clinician will stay with you and send emergency help to the address you gave. In an emergency, don't send a message or wait for a visit. Call 911 or go to the nearest emergency department. In a mental health crisis, call or text 988. PRIVACY, PEOPLE ON THE CALL, AND RECORDING A virtual visit is as confidential as one in the office. Your clinician joins from a private room. Our safeguards: [Such as an encrypted platform with a waiting room, no video stored, and staff training] No technology is completely secure. Information can be intercepted, sent to the wrong person, or seen by someone else using your device. Email and text are less secure than the portal, so we use them only for what you agreed to above. Your part: join from a private place, use your own device if you can, and avoid public Wi-Fi. Your clinician will tell you if anyone is with them, such as a student or an interpreter, and ask first. Tell your clinician if anyone is with you. No one records a visit, by audio, video, or screenshots, without everyone agreeing first. This applies to us and to you. Recording or AI scribe at this practice: [None, or what is used, what is kept, and the separate consent it needs] YOUR CHOICES AND COSTS Virtual care is your choice. You can ask for an in-person visit instead, or stop a virtual visit, at any time. Saying no will not change your care. To withdraw this consent: [Who to tell, and how] Costs: [What virtual visits cost, whether your plan covers them, and any fee for messages or missed visits, or no charge] CONSENT I have read this form, or had it explained, and my questions have been answered. I agree to virtual care in the ways I marked above. I understand its limits and privacy risks, and that I can ask to be seen in person or withdraw at any time. Patient or person giving consent: [Signature, printed name, and date] How consent was given: [Signed on paper, signed electronically, or verbal and recorded below] Taken by: [Name, role, and date] Interpreter: [Name or ID and language, or none] This consent covers: [All virtual visits with this practice until withdrawn, or this visit only] FOR THE CLINICIAN Verbal consent script, before the first virtual visit: Before we start, a few things about seeing you by [video or phone]. It works well for a lot of care, but I can't examine you the way I would in the office, so if I think you need to come in, I'll tell you and help you book it. We use [platform name], and I'm in a private room, but no technology is completely private. Where are you right now, and what's the best number to call if we get cut off? If something urgent happened during our call, I would send help to that address. Is anyone with you? Nothing is recorded unless we both agree. You can ask to switch to an in-person visit at any time. Are you OK to go ahead by [video or phone]? At later visits: Can you confirm where you are today, and that you're somewhere private? Line for the chart: Virtual care consent: [verbal or written] consent from [the patient, or the name and relationship of the person consenting] on [date] for [video, phone, messages, or email]. Explained the limits of a remote assessment and when an in-person visit is needed, privacy and platform limits, [the risks of email or text, if offered,] no recording without consent, and the right to stop or switch to in person. Location: [address]. Callback: [number]. Emergency contact: [name and phone]. Others present: [names and roles, or none]. Patient explained back [the main points].
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice; form signed electronically 2 days before the visit, confirmed at the start
Hannah Lewis, born April 9, 1985, age 41. New to the practice after moving to the area in October; registered through the online portal on November 3, 2026. Gives her own consent. Takes levothyroxine, with a month’s supply left, and sent a week of home blood pressure readings. Clinician: Dr. Samuel Reyes, family physician, joining from his office at the clinic.
Video visits: yes, on the practice’s encrypted video platform, joined through the portal. Phone visits: yes. Portal messages: yes, for booking, results, and refills. Text: appointment reminders only. Email: declined for anything clinical. Replies within 2 business days. Video and phone visits are covered the same way as office visits under her plan; a missed visit without 24 hours’ notice costs $40, as in the office.
Joining from home; full street address on the form and confirmed aloud. Callback: her mobile, checked at the start. Emergency contact: her partner, Tom Lewis. If the call drops, Dr. Reyes calls her mobile within 5 minutes. Given 911 for emergencies and 988 for a mental health crisis.
Platform: encrypted, with a waiting room, and stores no video. Dr. Reyes in a closed office. A third-year medical student, Aisha Rahman, joined with Hannah’s agreement, asked before the student came on screen. Hannah was alone. No recording. The practice’s AI scribe was offered on its own form; she agreed to it separately.
Signed electronically in the portal on November 10, 2026, at 7:42 p.m. At 9:00 a.m. on November 12, Dr. Reyes confirmed her identity with photo ID held to the camera, her address and callback number, and that the student could stay. He explained that this visit would cover her history, medicines, and readings, and that an exam, a clinic blood pressure, and blood tests need the office. She asked whether the video was saved anywhere: no. She asked whether she could send photos of a rash later: yes, through the portal, not by email. Home readings averaged 148/94 over 7 days. Decision: office visit booked for November 24; levothyroxine renewed for 3 months.
Virtual care consent: written consent from the patient, signed electronically on November 10, 2026, for video, phone, and portal messages; text for reminders only. Explained the limits of a remote assessment and the need for an office visit for an exam, blood pressure, and bloods; platform safeguards and limits; no recording; the right to switch to in person. Location: home, address confirmed. Callback: mobile. Emergency contact: Tom Lewis, partner. Others present: medical student, with consent. Patient explained back when she’d need to come in.
Counseling practice; verbal consent at the start of the first phone session, recorded in the chart
Kezia Thompson, 29, in individual CBT for depression with Rosa Delgado, counselor, in person every 2 weeks since March 2026. PHQ-9 18 at intake, 9 at her last session on October 23. Started a night-shift job and can’t reach the office during opening hours. Asked to switch to phone sessions; video isn’t workable on her data plan, and she shares a small apartment with a roommate.
Phone sessions: yes, 50 minutes, every 2 weeks; Rosa calls her at the booked time. Video: offered, declined for now. Portal messages: yes, for scheduling and the between-session worksheet. Text: reminders only, with no clinical details. Email: declined. $140 per session, as in person; she checked that her benefits plan pays for phone sessions at the same rate. The 24-hour cancellation policy is unchanged.
Usual spot: her parked car outside her apartment building, so her roommate can’t overhear; street address confirmed aloud and on file. She’ll say at the start of each call if she’s somewhere else. Callback: her mobile. Emergency contact: her sister, Monique Thompson. Her safety plan, last updated in July, still names Monique and 988. If Rosa believes she is in danger during a call, Rosa stays on the line and sends help to the address she gave.
Rosa takes calls from a closed office. If someone comes near the car, Kezia will say “Can we pick this up next week?” and Rosa will switch to yes-or-no questions, or end the call and phone back at a time Kezia names. She asked whether she could record sessions to listen to later. Agreed instead: neither of them records, and Rosa sends a short written summary of each week’s practice task through the portal.
Explained what changes by phone: Rosa can’t see her face or body language, so she’ll check in more often on how Kezia is feeling. In-person session every 3 months, the first on February 4, 2027, and sooner if her PHQ-9 rises by 5 points or more, if she has thoughts of ending her life, or if she asks.
At 7:30 a.m. on November 6, 2026, at the start of the first phone call, Rosa read the practice’s script and went through the form’s main points. Kezia agreed to phone sessions and portal messages, with text for reminders only. In her own words: “If you think I need to come in, you’ll say so, and if I’m not safe, you’ll send someone to where I am.” Copy of the form sent through the portal for her records.
Virtual care consent: verbal consent from the client on November 6, 2026, for phone sessions and portal messages; text for reminders only; video and email declined. Explained the limits of phone sessions and when an in-person session is needed, privacy and the risk of being overheard, no recording by either party, and the right to switch to in person. Location: parked car outside her building, address confirmed. Callback: mobile. Emergency contact: Monique Thompson, sister. Others present: none. Safety signal agreed. Client explained back the in-person and emergency plan.
Most rules ask you to explain the limits and privacy risks of virtual care and to record the patient’s consent; many accept verbal consent. These are examples: other states, provinces, and professions have their own rules.
Who the patient is, how to reach them if a visit drops, and who is agreeing: the patient, or someone who decides for them.
Avoid: Taking the number on file as the callback. Ask for the one the patient has with them, and check it.
Each kind of virtual care, with its own yes or no, because the risks differ. A video visit or a portal message is not the same as an email or a text.
Avoid: One signature that covers “electronic communication.” A patient may want video visits and still not want results by email.
An honest account of a remote assessment: what works well, what can’t be done, and how the patient will be seen in person when they need to be.
Avoid: Promising that everything can be done virtually. Patients need to know there is a way in to the office, and how fast.
Where the patient is decides where you send help, and whether you can see them there at all. Ask at every visit.
Avoid: Writing “at home” without the address. In an emergency, you need a street address, not a city.
How you protect the visit, what can still go wrong, who can hear it on either side, and that nothing is recorded without agreement.
Avoid: Calling the platform “fully secure.” Say what you do to protect it, and that no technology is risk-free.
Virtual care is optional, and the patient can change their mind. Put any cost in writing before the first visit.
Avoid: Charging for a missed video visit when the patient never saw a fee in writing.
Consent can be signed or verbal, as the rules where you practice allow. Either way, a short line in the chart records what was explained.
Avoid: A signed form with nothing in the chart. Note what you explained and what the patient asked, as you would for any consent.
Patients join from work, a car, or another city. Ask where they are at the start of every visit, with a street address, and write it down.
Ask again when something changes: video to phone, adding email or text, a new platform, or a recording. The first signature didn’t cover what the patient wasn’t told.
Agree before the visit who calls whom, on which number, and how fast. A patient in distress left on a frozen screen is the case to plan for.
When a hands-on exam, a measurement, or a test would change the plan, book the office visit, with a date, and record why.
Vero Scribe drafts the consent record and the chart line in your template from the start of the visit, with the patient’s consent, or from your dictation: how they’ll be seen, where they are, the callback number, the emergency contact, who is on the call, and what they agreed to. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Who the patient is and who is consenting; each way you’ll provide care, such as video, phone, portal messages, or email, with a yes or no for each; what virtual care can and can’t do and when an in-person visit is needed; the patient’s location and an emergency plan; privacy safeguards and their limits; who is on the call; recording; the right to stop or switch to in person; costs; and the signature or a record of verbal consent.
Often, yes. Many rules accept verbal consent recorded in the chart, and some ask for more in certain cases, such as using less secure technology. Check the rules where you practice. Either way, write down what you explained, the patient’s questions, and their answer.
Usually not the full discussion. Get consent before the first virtual visit, and again when something changes, such as moving from video to phone, adding email, a new platform, or a recording. Confirm the patient’s location and privacy at the start of every visit, and note it.
Yes. Telehealth, telemedicine, and virtual care mean the same thing in different places. This form covers video and phone visits, and also secure messages and email, which some forms leave out.
This form is the agreement: what virtual care involves, the risks, and the patient’s choices. The visit note records each visit, with one line saying consent is in place and where the patient was that day. Use both.
Only with their consent, after explaining the risks: messages can go to the wrong person or be seen by someone else using the device. Agree what email or text is for, such as reminders only, and keep results and clinical questions in a secure portal where you can.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient leaving or refusing care: the recommendation, capacity, risks in plain words, alternatives, signature or refusal to sign, and the care still given.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
Consent to a procedure or treatment: benefits, risks, alternatives, capacity, signatures, and the discussion note.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Screening questions, consent or declination, and a record of each dose: lot, expiry, site, observation, and the next dose due.
Video and phone visit notes, drafted from the call for your review.
Patient-specific consent forms from your clinic’s own templates.
The note for each video or phone visit: location, what you could see, and next steps.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.