This form is required for all patients scheduling a virtual medical consultation (Telehealth). Please complete all sections before your scheduled appointment.
First Name
Middle Name
Last Name
Date of Birth
Street Address Line 1
Street Address Line 2
City/Town
State/Province
Postal/Zip Code
Primary Phone
Secondary Phone
Email Address
Preferred Language
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Reason for Visit
Referring Provider (If Applicable)
Type of Telehealth Service
Video Call (e.g., Zoom, Secure Platform)
Phone Call
Location You Will Be In During Appointment (State the city/region/country)
Technology You Will Use
Smartphone
Tablet
Desktop/Laptop
Landline Phone
Connection Test Completed? (For Video Only)
Is this your first Telehealth appointment with us?
List all current medications (including over-the-counter and supplements):
Medication Name | Dosage | Frequency | ||
|---|---|---|---|---|
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
List all known drug allergies and reaction:
Drug Allergy | Reaction | ||
|---|---|---|---|
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Measurement | Value | Notes (e.g., Time Taken) | |
|---|---|---|---|
Current Weight | |||
Current Height | |||
Blood Pressure | |||
Heart Rate/Pulse | |||
Temperature |
Please describe your primary concern/symptoms in detail:
When did this problem start?
What makes the symptoms better or worse?
By signing below, I acknowledge and agree to the following terms and conditions for my virtual appointment with [Clinic/Practice Name]:
Nature of Telehealth: I understand that Telehealth involves the use of electronic communications to enable healthcare providers at a different location to share information for the purpose of improving my health care. I understand there are potential risks to this technology (e.g., connection interruptions, security breach) and I accept these risks.
Privacy and Security: I understand that [Clinic/Practice Name] will use reasonable efforts to ensure the confidentiality of my personal health information, and that the communication platform is a private and secure channel.
Physical Location: I confirm the physical location I will be in during the consultation and agree to notify the provider if my location changes. I understand that my location may impact the provider’s ability to offer services or coordinate care.
In-Person Care: I understand that Telehealth is not a substitute for in-person evaluation, and I agree to seek immediate emergency care or schedule an in-person visit if my provider advises it or if my condition worsens.
Emergency Protocol: I understand that Telehealth is NOT for medical emergencies. If I am experiencing a medical emergency, I will immediately call my local emergency services number or go to the nearest emergency department.
Payment and Billing: I understand and agree to the payment policies outlined by [Clinic/Practice Name]. I am responsible for verifying coverage with my insurance provider (if applicable).
Right to Stop: I understand that I have the right to request an in-person appointment or stop the Telehealth consultation at any time.
Patient/Guardian Signature
Provider Name
Date & Time of Appointment
Platform Used (e.g., Zoom/Phone)
Pre-Appointment Check Completed