Great Plains Telehealth Resource & Assistance Center : Resources : Sample Forms

Use these forms as samples to help develop ones for use in your telehealth program.

Telehealth Consent Form 1

A sample consent form for telehealth.
Telehealth Consent Form 2

A sample telehealth consent form.
Telehealth Consent Form 3

A sample telehealth consent form.
Telehealth Consent Form 4

A sample telehealth consent form.
Patient Telehealth Evaluation Form

A sample telehealth patient evaluation form.
AHRQ Patient TM Evaluation Form

A sample telehealth evaluation form from AHRQ.

Resources