Patient Confidentiality Agreement

About this template

Give your patients peace of mind that their sensitive medical data is safe with this Patient Confidentiality Agreement. Simply customize this template however you see fit, then share your form via email. Patients can then fill out this agreement form from any smartphone, tablet, or desktop computer. You’ll receive an email notification and a signed and finalized version of the document in your online dashboard.

Make changes to this Patient Confidentiality Agreement with our drag-and-drop builder. Change the agreement terms, add new text boxes or signature fields, upload your clinic’s logo, choose fonts and colors, and much more without any coding knowledge. Once a patient fills out and signs your document, you can instantly print and download it as a PDF document for your records. Say goodbye to messy paperwork and keep everything safe and secure with Jotform Sign.

Related templates

Background Check Template

Create a custom background check form for your business. Converts into PDF. Easy to share and embed. Works on any device. Android and iOS compatible. No coding.

Online Therapy Consent Template

Create an online therapy consent form to gather patient consent. Sign and fill out on any device. Drag and drop to fully customize. No coding knowledge required.

General Release of Liability Form

Create a liability form for any and all of your needs. Works on all desktop, tablet, and mobile devices. Drag and drop to customize. Collect e-signatures.

Summer Camp Permission Slip

Create summer camp permission slips for parents of your campers. Intuitive form building. Drag and drop to design. Works on desktop, tablet, and mobile devices.

Professional Physical Therapy Consent Template

Create a professional physical therapy consent form. Collect e-signatures on any smartphone, tablet, or desktop. Easy to customize and share.

Insurance Waiver Template

Create an insurance waiver for employees declining insurance coverage. Works great on any device. Easy to customize and share. No coding knowledge required.

The e-sign templates here are for informational purposes only. Jotform is not providing legal, financial, or other advice, or implying that the forms are legally valid in all or any jurisdictions. Before using any such template, consult an attorney and/or other applicable professionals to make sure that the form meets your needs, legally and otherwise.