Telehealth Consent template

A telehealth consent form covering the disclosures video-visit programs typically document: how virtual visits work, their limits, what happens when a call drops, and the patient's right to decline. It also asks which state the patient will be in during visits — the licensing detail that catches many telehealth workflows off guard — and closes with a signature.

Use this template Start free — no card

8 questions · works on the free plan (500 responses/month) · fully customizable

E-signature question

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01How telehealth visits workStatement

02Your full legal nameShort text

03Date of birthDate

04Which state will you be in during your visits?Short text

05Please confirm each of the followingCheckboxes

06Sign to confirm your consentE-signature

When to use this template

A practice adding video visits and needing documented consent from each patient before the first one
A therapy group whose clients split time between two states, making the state-of-location question load-bearing
A telehealth-first startup building consent into its patient onboarding flow
A clinic replacing a scanned-PDF consent process that patients kept returning unsigned or half-legible

Tips to get more from it

The "How telehealth visits work" statement is display-only text — rewrite it to describe your platform, your dropped-call procedure, and your recording policy before publishing
The four acknowledgments are a required multi-select, so patients confirm each point individually — what telehealth is, its limits, technical interruptions, and the right to stop — rather than one blanket agreement
The state question exists because providers can only see patients in states where they're licensed; consider a dropdown of your licensed states if the list is short
The signature field requires the Pro plan to publish — the rest of the form runs on free

Questions people ask

Why does a telehealth consent form ask what state I'll be in?

Provider licensing is state-based, so practices document where the patient will be located during visits. The template includes this as a required question with an explanation patients see inline.

Is the signature on this form legally binding?

Zunoform records a drawn signature with the submission and its date. Whether that satisfies your documentation requirements depends on your jurisdiction and policies — confirm with your compliance advisor.

Do I need a paid plan to use this consent form?

Publishing it as-is requires Pro at $14.99/mo because of the signature field. If you replace the signature with a typed-name confirmation, the form publishes on the free plan.