Free Telemedicine Visit Consent Form Template

Informed Consent for Telemedicine and Virtual Health Visits

Patient Informed Consent Documentation

Patient and Provider Information

1. Nature and Scope of Telemedicine Services

Telemedicine involves the delivery of healthcare services using interactive audio, video, and data communications between a patient at one location (the originating site) and a provider at another location. These virtual visits may be used for medical consultations, diagnosis, treatment planning, prescription refills, or follow-up care. The technology used must meet security standards to protect your privacy. A typical session involves a live, face-to-face video call through a secure clinical portal. The provider may also review digital medical records, laboratory results, or uploaded photographs during the session.

2. Technology and Connectivity Requirements

3. Backup Protocol for Connectivity Failures

If the video connection drops or fails during your virtual visit, the provider will attempt to reconnect through the platform twice. If video cannot be restored, the provider will immediately call you at the primary phone number listed in your registration file. Depending on the nature of your visit and clinical guidelines, the appointment may be completed over the phone, or rescheduled for a later date or in-person visit.

4. Security, Privacy, and Confidentiality Disclosures

5. Risks and Limitations of Virtual Care

6. State Licensing Compliance Requirement

Under medical licensing regulations, a healthcare provider must be licensed in the state where the patient is physically located at the time of the virtual visit. You must accurately disclose your physical address and state location in the admin info section. If you are located in a state where the provider is not licensed, the visit must be canceled or rescheduled.

7. Local Emergency Protocol

In the event of a medical emergency during your virtual visit (such as chest pain, severe shortness of breath, or loss of consciousness), the provider will instruct you or your caregiver to hang up and dial 911 immediately. The provider will also call 911 on your behalf and share your physical address (as documented in this form) with emergency dispatchers.

8. Alternatives to Telemedicine

9. Insurance and Billing Disclosures

Telemedicine visits are billed to your health insurance in the same manner as in-person visits. Co-pays, deductibles, or non-covered service fees apply. You are advised to check with your insurance provider to confirm your virtual care benefits. If your insurance plan does not cover telemedicine, you are responsible for the self-pay fee of the visit.

10. Right to Withdraw Consent

You have the right to withdraw your consent to telemedicine services at any time. Doing so will not affect your right to receive future in-person care at this clinic.

11. Patient Understanding and Questions

I confirm that I have read this document and understand how telemedicine works, its technology requirements, the limitations of virtual diagnosis, the licensing rules, and the billing policy. My questions have been answered.

12. Language Access Services

If English is not your primary language, a qualified interpreter is available at no cost. Please inform staff before signing.

13. Patient Authorization

I voluntarily consent to participate in telemedicine and virtual health visits. I authorize the electronic transmission of my medical information. I confirm my physical location is accurately reported and agree to follow the emergency protocol if needed.

Signatures and Verification