Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Telehealth Psychiatry Registration
Patient Full Name *
Email Address
Phone Number
Physical Address (for emergencies)
Emergency Contact
Name
Relationship
Phone
Device Type for Sessions
- Smartphone
- Tablet
- Computer
Internet Connection Quality
- Reliable
- Sometimes disconnects
- Unreliable
- Not sure
Preferred Session Times
- Morning
- Afternoon
- Evening
- No preference
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 Psychiatry Registration template from formisoft.com. formisoft.com/intake-templates/telehealth-psychiatry-registration