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Telehealth Consent for Minors Form
Consent

Telehealth Consent for Minors Form

3 pages•12 fields•HIPAA-ready
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Telehealth Consent for Minors Form

Telehealth Consent for Minors Form

Page 1 of 3

Minor Patient Full Name
Jane Martinez
Patient Date of Birth
03/15/1985
Parent or Guardian Full Name
Jane Martinez
Guardian Phone Number
(555) 867-5309
Guardian Email Address
jane.martinez@email.com
Patient Location During Visit
Technology and Privacy Risks Acknowledged
Item 1 assessed
Item 2 assessed
Item 3 assessed
Limitations of Telehealth Acknowledged
Guardian Available During Session
Option A
Option B
Option C
Consent for Provider to Treat Minor
I agree to the terms above
Sign here
Guardian Signature
Sign here
Date of Consent
03/15/1985
Submit
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The Telehealth Consent for Minors Form addresses the unique legal and practical requirements of delivering virtual healthcare services to patients under 18 years of age. It combines standard telehealth informed consent elements with the additional authorization requirements mandated when treating minor patients, ensuring both the provider and the guardian are aligned on expectations.

This template covers essential telehealth disclosures including the technology platforms used, privacy and security measures for video consultations, limitations of virtual examinations compared to in-person visits, and circumstances that would require an in-person follow-up or emergency room visit. It also addresses the guardian's responsibility to be present or available during the minor's telehealth session and consent for the provider to communicate directly with the child during treatment.

Ideal for pediatric practices, family medicine clinics, behavioral health providers serving adolescents, and school-based telehealth programs, this form ensures compliance with both telehealth regulations and the additional consent requirements for treating minors across state jurisdictions.

What's included

  • Minor patient and guardian identification
  • Guardian contact information and relationship
  • Patient location and technology requirements
  • Telehealth privacy and security disclosures
  • Limitations of virtual care acknowledgment
  • Guardian signature and authorization for minor treatment
  • Consent agreement with e-signature

Who uses this template

  • Obtaining parental consent for pediatric telehealth visits
  • Documenting guardian authorization for virtual behavioral health services for adolescents
  • Meeting state telehealth regulations for treating minor patients remotely
  • Ensuring guardians understand privacy and technology requirements for virtual care

All form fields

12 fields across 3 pages. Customize any field after signing up.

Minor Patient Full NameText
Patient Date of BirthDate
Parent or Guardian Full NameText
Guardian Phone NumberPhone
Guardian Email AddressEmail
Patient Location During VisitText
Technology and Privacy Risks AcknowledgedCheckbox
Limitations of Telehealth AcknowledgedCheckbox
Guardian Available During SessionMultiple Choice
Consent for Provider to Treat MinorConsent Agreement
Guardian SignatureE-Signature
Date of ConsentDate
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