Telehealth Informed Consent
For medical, mental health and allied health practices offering video or phone visits. Many states require documented consent for telehealth, and the emergency plan and location questions matter for every session.
- Fields
- 21
- Pages
- 2
- Paper
- Letter
Fill it online without an account. The blank PDF is free to download and works in any PDF reader. Downloading a filled copy from the editor needs a free account — 3 downloads a month, no watermark. See plans
Reviewed
Before you start
What you need to fill it in
- Practice and patient names
- Platforms you use (video service, phone)
- Patient's usual location during visits and state
- A local emergency contact and the nearest emergency facility
What's inside
21 fields, ready to fill
- 13Typed answersnames, addresses, descriptions
- 2Dateschecked as real dates
- 5Choicescheckboxes, options, dropdowns
- 1Signaturessignature and initials
9 required — the editor counts down how many are left while you fill.
Instructions
How to fill out the Telehealth Informed Consent
- 1
Practice and patient details
Enter both and the services offered by telehealth.
- 2
Explain the technology
List the platforms you use. Patients check which they agree to.
- 3
Record location and emergency plan
Enter where the patient usually joins from, a local emergency contact and the nearest emergency facility.
- 4
Review risks and rights
Patients read the risks and their rights, including choosing in-person care.
- 5
Sign
The patient signs; confirm location at the start of each visit.
Fill it online
What filling it looks like
- Edit & fill, Invite to sign and Create form are three modes of the same editor
- Amounts are formula fields: they calculate as you type
- The field navigator counts what's left and jumps to the next field
Shown with our invoice template. Sample content; names are fictional.
Written for: General (US)
This template is a general starting point, not medical or legal advice. HIPAA, state privacy and consent rules vary; have your compliance lead or a qualified professional review it before use.
Written by PDFBetter and last reviewed October 15, 2026. Spotted a problem? Tell us.
Telehealth Informed Consent: questions people ask
Is written telehealth consent required?
Requirements differ by state and by payer. Some states require documented consent; others accept verbal consent recorded in the chart. A signed form covers both cases.
Why does the patient's location matter?
Clinicians generally must be licensed in the state where the patient is located during the visit, and emergency services depend on where the patient is.
Are consumer video apps allowed?
Use a platform that will sign a business associate agreement and meets your privacy obligations. Temporary federal flexibility for non-compliant apps ended in 2023.
Can patients e-sign this consent?
Yes, electronic signatures are commonly used for telehealth consent and are generally valid under US law.
Ready when you are
Fill the Telehealth Informed Consent now — no account to start.