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Telehealth Consent Form Template

A printable telehealth consent form covering how virtual visits work, the privacy and technology limits, the client's location and emergency plan, and whether sessions are recorded.

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Last reviewed September 2026 · Not legal advice

The emergency plan is the part that matters

Video care is convenient, but you cannot walk down the hall. Record where the client will be for each session and how you would reach local emergency services if needed. This is the most important line on a telehealth form.

Also explain the privacy limits of the technology, the expectation of a private space, and that recording is not allowed unless agreed. Check your regulator's guidance on telehealth, including where the client must be located for you to treat them.

Clinic name · address · phone

Telehealth Consent Form

Client

Full name

Date of birth

Phone

Details

Usual location for sessions

Emergency contact and phone

Preferred video platform

Acknowledgements

Initial each item.

InitialsI understand telehealth is delivered by video or phone and has technology and privacy limits.

InitialsI will attend from a private place and tell my practitioner if my location changes.

InitialsI agree not to record sessions unless agreed in writing.

InitialsI understand that if the connection fails, my practitioner will contact me by phone.

InitialsI understand my practitioner may recommend an in-person visit when it is not suitable to continue virtually.

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/telehealth-consent-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for therapy practices.

Frequently asked questions

Why record the client's location?

It tells you where to send help in an emergency, and it may affect whether you are permitted to treat them.

Do I need a separate form for each platform?

No, but name the platform and its limits.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.