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Telehealth Intake & Signature Form Template Template

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Telehealth Intake & Signature Form Template Template
Use Template

The Telehealth Intake & Signature Form Template is a ready-to-use digital solution for clinics, doctors, and healthcare providers offering telemedicine services. This form helps you collect essential patient details, obtain consent for virtual care, and capture secure e-signatures — all in one organized place. Whether you're conducting video consultations or offering ongoing remote care, this template ensures compliance, enhances patient experience, and simplifies your workflow.

Key Form Tables/Sections Included

  1. Patient Information

    Collect vital personal and contact details including full name, date of birth, address, insurance provider, and emergency contact.
  2. Medical History
    Record patient-reported conditions, allergies, medications, and prior treatments. Crucial for giving care providers full context before teleconsultation.
  3. Telehealth Consent Form
    Outline what telehealth services include, the limitations of remote care, data privacy notices, and capture a checkbox consent with digital signature.
  4. Electronic Signature
    A dedicated section for capturing patient or guardian's digital signature and date, ensuring legal compliance for remote medical treatment.
  5. Appointment Details
    Track the reason for the telehealth visit, scheduled date/time, assigned provider, and consultation platform (Zoom, Doxy.me, etc.).
  6. Follow-up and Notes
    Use this to add provider’s post-consultation notes or follow-up instructions for patient continuity and documentation.

Key Features

  • Secure Digital Intake: Eliminate paper forms by collecting patient details directly online before appointments.
  • Built-In Consent Workflow: Automatically document informed consent to comply with HIPAA and telemedicine regulations.
  • Customizable Fields: Add or remove fields to fit your specialty or practice requirements (e.g., pediatric, mental health).
  • Time-saving: Pre-fill sections or auto-populate from EHR integrations to save admin hours.
  • Mobile-Responsive Design: Patients can complete and sign the form from any device — desktop, tablet, or phone.
  • Easy Export & Integration: Download as PDF, or connect to systems like Google Sheets, Stackby, or Zapier for workflow automation.

 Benefits

  • Improved Patient Onboarding: Reduce errors and back-and-forth emails by collecting all relevant info in one go.
  • Legal & Compliance Ready: Securely store signed consents in compliance with telehealth and data protection laws.
  • Faster Consultations: With accurate, upfront data, providers can focus on treatment rather than admin.
  • Professional Presentation: Present a modern and efficient digital front for your virtual health services.
  • Track & Monitor Intakes: With integrated databases, track patient submissions, pending signatures, and appointment statuses.

 Use Cases

  • Private Practice Clinics: Enable streamlined patient intake and signature collection for teleconsultations.
  • Mental Health Therapists: Use the form to collect therapy consent, intake history, and signatures remotely.
  • Group Practices & Networks: Deploy across teams and locations with standardized yet customizable fields.
  • Pediatric & Geriatric Telehealth: Add guardian/relative info or special care notes for vulnerable patients.
  • Specialists: Tailor fields for dermatology, cardiology, or other specializations by modifying the form template.

 How to Use This Template

  1. Clone or import the form into your Stackby workspace or connected app.
  2. Customize the fields to fit your medical practice (optional).
  3. Share the form link with patients via email or SMS before scheduled appointments.
  4. Automatically store or export responses to your patient records system.
  5. Stay organized, secure, and legally compliant.

This Telehealth Intake & Signature Form Template is perfect for any healthcare provider aiming to modernize patient onboarding and ensure compliance in their virtual care setup. With customizable fields and integrated digital signatures, it’s designed to make remote healthcare delivery seamless and secure.

Would you like this copy exported as a downloadable file or added to your content management system (CMS) format? 

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