Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Telehealth Consent for Minors Form
Your information
Minor Patient Full Name
Patient Date of Birth
____ / ____ / ________
Parent or Guardian Full Name
Guardian Phone Number
Guardian Email Address
Patient Location During Visit
Additional details
Technology and Privacy Risks Acknowledged
Limitations of Telehealth Acknowledged
Guardian Available During Session
Consent for Provider to Treat Minor
Your practice's consent wording goes here.
Signature
Date
Guardian Signature
Date
Date of Consent
____ / ____ / ________
Telehealth Consent for Minors Form template from formisoft.com. formisoft.com/intake-templates/telehealth-minor-consent