Telehealth Intake and Signature Form

Telehealth Intake and Signature Form
Patient Information
Patient Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Gender
MaleFemaleSpecify
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Email
example@example.com
Emergency Contact
Emergency Contact List
Insurance Information
Insurance Carrier
Insurance Plan
Policy Number
Group Number
Contact Number
Referrals and Adjunctive Care
Are you currently under medical care?
YesNo
You are under medical care for
Primary Care Physician
First NameLast Name
Health Concerns
Please explain your health concerns or symptoms
When did the problem, illness or symptoms begin?
MonthDayYear
Date
Consent to Participate in Telehealth
1. Service
The healthcare facility will need to collect and record the patient's personal and medical information. During the telehealth visit, the patient will be contacted via videoconference software.
If the videoconference cannot be held during the appointment time, the patient will be called via phone which is stated in the form.
2. Software
Telehealth visits are held by using different software in order to increase the productivity and effectiveness of the visits. All information is password-protected.
3. Confidentiality
All the medical or personal information of the patient will be kept private. The medical condition of the patient will be used for further researches anonymously.
4. Rights
The patient can withdraw or withhold the consent at any time and it will not affect the further treatment.
The patient can end the videoconference with the healthcare consultant, physician, or professional at any time.
Signature and Submission
I have informed about the telehealth practices and I have been given the opportunity to ask questions about services, consultation, and practice. I have acknowledged that the information I have given in the form is accurate and complete. I have understood and given my consent to participate in telehealth services.
Patient Name
First NameLast Name
Signed By (if signed by other person than patient)
First NameLast Name
Relationship to Patient (if signed by other person than patient)
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Telehealth Intake and Signature Form

Patient Information

Emergency Contact

Insurance Information

Referrals and Adjunctive Care

Health Concerns

Consent to Participate in Telehealth

Signature and Submission