Example Telehealth Consent Form

Some professions require clients to consent to receiving services via Telehealth. We've included below an example of what an emailed Telehealth consent form might include. If you'd like to use this you can open this text file  and copy and paste the content into a new email template in your Power Diary account (Tools > Communication > Templates, +New Template).

Our rather obvious disclaimer: This is an example consent form only. It may or may not be suitable for your professional context, but we do hope it is at least helpful :)


Hi {ClientFirstName}

During your treatment with us you may be provided with service via Telehealth. The information below is a consent form to enable us to provide services to you in this way.  Please read the information and reply 'I agree' or similar to confirm your consent to receive Telehealth services.
Please read the information below and then to consent reply "I agree". 
Kind Regards,
{BusinessName}
Consent for Provision of a Telehealth Service
Where appropriate the services you receive may be provided by telephone or videoconferencing. You are responsible for the costs associated with setting up the technology needed so you can access telehealth services. {BusinessName} will be responsible for the cost of the call to you and the cost associated with the platform used to conduct telehealth services. 
To access telehealth consultations you will need access to a quiet, private space; and the appropriate device, i.e. smartphone, laptop, iPad, computer, with a camera, microphone and speakers; and a reliable internet connection. 
The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information this practice uses Power Diary which is compliant with the Australian standards for online security and encryption. You can read more about Power Diary's Security Privacy and Compliance measures here.
Limitations of Telehealth
A telehealth consultation may be subject to limitations such as an unstable network connection which may affect the quality of the session provided. In addition, there may be some services for which telehealth is not appropriate or effective. Your practitioner will consider and discuss with you the appropriateness of ongoing telehealth sessions. 
Consent to Receive Services by Telehealth
I, {ClientFullName} have read and understood the information in this Consent Form and have discussed any outstanding questions with my practitioner. By replying "I agree" or similar I consent to receiving services via telehealth.
Please reply "I agree" to this email, or if you have further questions please reply to let us know. 

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