Telehealth consent form template (free, Australia)

Here’s a free telehealth consent form for Australian practices. It’s two pages, written in plain English for patients, and you can change it however you like.

Download: Word (.docx) · PDF

The parts for you to fill in are in [square brackets] and highlighted in the Word version. The full text is further down this page.

What the form covers, and why

We built it from what Australian regulators, colleges and medical defence organisations say patients should know before a telehealth consult. We checked those sources in October 2026.

The form explains	Why it’s there
What telehealth is, and who the practitioner is	The Medical Board expects you to identify yourself and confirm who the patient is (MBA guidelines).
Its limits, and that they may need to be seen in person	Patients should know they may need an in-person visit, and that there are alternatives to telehealth (MBA guidelines).
A private place, who else is present, support people and interpreters	Patients should know who can see or hear the consult, and that they can bring support people or an interpreter (MBA guidelines; RACGP).
Their location and a call-back number	Defence organisations suggest recording where the patient is and having a number to call back (MDA National; Avant).
What happens if the connection drops	The Medical Board expects patients to know what to do if the technology fails (MBA guidelines).
Emergencies and worsening symptoms	Patients should leave with a plan if things get worse (Ahpra).
Privacy, where the platform is hosted, recording and AI scribes	Ahpra expects you to tell patients if a consult is recorded or an AI scribe is used. Privacy law requires you to say whether information goes overseas (Ahpra; OAIC).
Fees and Medicare eligibility	Informed financial consent is expected before the service, including out-of-pocket costs (MBA guidelines).
Scripts, referrals, and sharing with their GP	Patients should know how they’ll get scripts and referrals, and that their GP will be told, with their consent (MBA guidelines).
Withdrawing consent and complaints	Consent has to be current and can be withdrawn. Patients should know how to complain (OAIC).

How to use it

1. Fill in the brackets. Add your practice details, your video platform and where it’s hosted, your fees, and how you send scripts and referrals.
2. Decide on recording and AI scribes. Most practices don’t record telehealth consults, and the form says so by default. If you use an AI scribe, keep its tick-box and explain whether audio is kept. Each of these gets its own tick-box because consent to treatment and consent to how information is handled are separate things under privacy law (OAIC).
3. Send it before the first appointment. Send it with the booking confirmation or put it on your website, so patients can read it before the consult.
4. Still confirm consent at the start of each consult, and note it in the record.

Do you need a signed form?

No regulator requires a signed form. The RACGP says verbal consent is fine as long as you document it, and the Medical Board says to apply the usual principles of informed consent (RACGP; MBA guidelines). Defence organisations suggest getting it in writing if a consult is recorded (MDA National). A form is a good way to make sure nothing is missed, but a documented verbal consent is just as valid.

If you take verbal consent, a short version at the start of the consult covers the essentials:

“Before we start, can you confirm your name and date of birth, and where you are right now? Is anyone with you? If we get cut off, I’ll call you on [number]. I can’t examine you over video, so if I think you need to be seen in person I’ll tell you. [Fee or bulk-billing statement.] Are you happy to go ahead by telehealth?”

Then note in the record that consent was given, who was present, the patient’s location, and the technology used. Our guide to informed consent for telehealth goes into more detail, and telehealth documentation covers what else to record.

The template text

Telehealth consultation consent
[Practice name] · [Address] · [Phone] · [Email]

This form explains how telehealth consultations work at [Practice name] and asks for your consent. Please read it, ask us about anything you’re not sure of, and sign at the end. You can change your mind at any time.

1. What a telehealth consultation is

• A telehealth consultation is an appointment by video or phone instead of in person. We use [video platform], which opens in your web browser. You don’t need to download an app.
• At the start, your practitioner will tell you who they are and check who you are, usually by asking your name and date of birth.

2. What telehealth can and can’t do

• Your practitioner can’t physically examine you by video or phone. If they decide you need to be seen in person, they’ll tell you and help you arrange it.
• Telehealth isn’t right for every problem. You can ask for an in-person appointment [with us / with another provider] instead, or choose not to use telehealth.

3. Before your appointment

• Find a private, quiet place with good light, where other people can’t overhear.
• Check your phone, tablet or computer is charged and that your camera, microphone and internet are working.
• At the start of each consultation, tell us where you are and the best number to call you on.
• Tell us if anyone is with you. We’ll introduce everyone and check you’re happy for them to be there. You’re welcome to have a support person.
• If you’d like an interpreter, tell us when you book. We can arrange a free interpreter through TIS National.

4. If the connection drops

• If the video or call drops, we’ll call you back on the number you gave us. If we can’t reconnect, we may finish by phone or book another time.

5. Emergencies

• Telehealth isn’t for emergencies. If you have a medical emergency, call 000.
• Before the consultation ends, your practitioner will tell you what to do if your symptoms get worse.

6. Privacy and recording

• We handle your health information under the Privacy Act 1988 and our privacy policy: [link to privacy policy].
• [Video platform] is hosted in [country]. [Add what details are shared with it, for example your name and mobile number.]
• We take reasonable steps to keep consultations private and secure, but no technology is completely without risk.
• We don’t record telehealth consultations. [If your practice does, change this and use the optional recording consent below.]
• Please don’t record the consultation without asking your practitioner first. They may say no.
• [Optional] Your practitioner may use an AI scribe to help write their notes. [Explain whether audio is kept and for how long.] You can say no, and it won’t affect your care.

7. Fees and Medicare

• [Your fees. For example: telehealth consultations are bulk billed for eligible patients. Or: our fee, the Medicare rebate, and your out-of-pocket cost.]
• Medicare rebates for telehealth have eligibility rules. Usually you need to have seen [our practice] in person in the last 12 months, or be registered with us in MyMedicare. If you’re not eligible, or you’re overseas, Medicare won’t pay a rebate and the full fee applies. We’ll tell you before your consultation if that’s the case.
• You pay for your own internet and phone data.

8. Scripts, referrals and test requests

• We’ll send prescriptions as an electronic script (eScript) by SMS or email, and referrals and test requests [by email / directly to the provider]. Tell us if you’d like a script sent to a particular pharmacy.

9. Sharing with your other health providers

• With your agreement, we’ll send a summary of your consultation to your usual GP or other treating practitioners.

10. Your rights

• You can withdraw your consent to telehealth at any time.
• If you’re unhappy with your care, please talk to us first: [contact details]. You can also contact the health complaints commissioner in your state or territory, Ahpra about a practitioner’s conduct, or the Office of the Australian Information Commissioner (OAIC) about privacy.

Your consent (tick each box that applies)

• ☐ I have read this form, or had it explained to me, and I’ve had the chance to ask questions.
• ☐ I consent to having consultations by telehealth with [Practice name].
• ☐ I understand the fees and how Medicare applies.
• ☐ Optional: I consent to my practitioner using an AI scribe during my consultations.
• ☐ Optional, only if your practice records: I consent to my consultation being recorded for [purpose]. I understand how the recording will be stored and that I can withdraw this consent.

Patient name, date of birth, signature and date. If someone is signing for the patient: their name, relationship and signature. Interpreter used: yes or no, and their name or ID.

Practice use only: consent obtained by, date, and method (signed form, or verbal and documented in the clinical notes).

Download: Word (.docx) · PDF

This template is general information, not legal advice. Adapt it to your practice and check it with your medical defence organisation. If you’d like a telehealth platform that keeps consult data in Australia and never records, that’s what MedCall does.