Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Telehealth Platform Enrollment Registration
Patient Name *
Email Address
Mobile Phone
Device Type
- Smartphone
- Tablet
- Computer
- Another device
Internet Connection Quality
- Reliable
- Sometimes disconnects
- Unreliable
- Not sure
Preferred Visit Type
- In person
- Video visit
- Phone visit
- No preference
Technical Assistance Needed
- Yes
- No
- Not sure
Caregiver Portal Access
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Telehealth Platform Enrollment Registration template from formisoft.com. formisoft.com/intake-templates/telehealth-platform-enrollment-registration