Skip to content
Askalot

← All Healthcare templates

Questionnaire template

Telemedicine Consent

Records whether patients understand telemedicine, accept its privacy terms and risks, and consent to remote care.

Preview

Healthcare · Patient consent. All Healthcare templates

Questions in this template

About Remote Care

  1. Thank you for taking a few minutes to review this form. It records whether you agree to receive some of your care remotely.

  2. In this form, telemedicine means care delivered from a distance using video calls, phone calls or secure messaging, used when meeting your clinician in person is not practical.

Your Understanding

  1. Is the description of telemedicine above clear to you?

    Choose one:

    • Yes
    • No

  2. Do you accept that a remote appointment can sometimes replace an in-person visit?

    Choose one:

    • Yes
    • No

  3. What would you like us to explain further?

    Condition: Shown when the description was not clear

    Open answer

Privacy

  1. Please tick each statement to confirm you have read and accept it.

    Choose any that apply:

    • My health information is protected under the applicable privacy laws.
    • Remote sessions take place in a private setting where others cannot see or hear my information.
    • Sessions are recorded on video, audio or image only with my separate permission.
    • Messages and files about my health are stored securely and encrypted.

Risks and Responsibilities

  1. Do you accept that remote care carries some risks, such as a lost connection, interrupted sessions or unauthorised access to data?

    Choose one:

    • Yes
    • No

  2. Do you agree to know how to get urgent care, such as calling emergency services, if a remote session cannot continue?

    Choose one:

    • Yes
    • No

Your Decision

  1. Having reviewed this information, do you freely agree to receive care through telemedicine?

    Choose one:

    • Yes
    • No

  2. If you would like to, tell us why you prefer not to use telemedicine.

    Condition: Shown when consent is declined

    Open answer