Clinic template
A Cliniko telehealth consent form template for clinics
This Cliniko patient form is completed before a video or phone consultation. It confirms the patient is in a private space, knows what to do if the connection fails, has given a location for emergencies, and understands the session will not be recorded without separate consent, reflecting the Medical Board of Australia's telehealth guidelines and the shared Code of conduct's informed consent rules.
Last checked 25 Sep 2026 against the sources listed at the end of this page.
Free template ยท Cliniko
Patient form: telehealth consent: allied health (general)
The template: 13 fields
| Section | Field | Type | Notes |
|---|---|---|---|
| What this covers | Explanation of scope | Text | Cliniko type: Paragraph text (description, not a question). State this consent covers video or phone consultations specifically and sits alongside the clinic's general treatment consent, not instead of it. |
| Your location and technology | Address you will attend this appointment from | Text | Captured so the practitioner has a physical location on file if emergency services need to be called during the consultation. |
| Your location and technology | Emergency contact name and phone number | Text | A second contact reachable if the patient cannot be, for use only if something goes wrong during the session. |
| Your location and technology | I confirm I am in a private space where others cannot see or hear this consultation unless I have chosen to include them | Checkboxes | Options: I understand and agree. |
| Your location and technology | I know what to do if the video or internet connection fails | Checkboxes | Options: I understand and agree. Pair with a Text description above stating your clinic's fallback, for example a phone call to continue or reschedule. |
| Privacy and recording | I understand this consultation will not be recorded unless I am asked and give separate consent at the time | Checkboxes | Options: I understand and agree. |
| Privacy and recording | I understand my clinical record from this consultation is stored securely in the same way as an in-person visit | Checkboxes | Options: I understand and agree. |
| Emergency and safety plan | I understand my practitioner cannot physically attend to me during this call and, if I need urgent care, I will call 000 or attend my nearest emergency department | Checkboxes | Options: I understand and agree. |
| Suitability and costs | I understand telehealth is not suitable for every situation and I may be asked to attend in person instead | Checkboxes | Options: I understand and agree. |
| Suitability and costs | I understand the fees for this consultation, and whether a Medicare rebate applies, have been explained to me | Checkboxes | Options: I understand and agree. |
| Sign off | Patient name | Text | Connected question, matches the patient record. |
| Sign off | Date | Text | Use Cliniko's Date question type here if a picker is wanted. |
| Sign off | Signature | Text | Captured however your Cliniko account's patient form signature option is configured. |
Build it in Cliniko
- Go to Settings > Patient form templates as an Administrator, click Add template and name it Telehealth consent.
- Write the What this covers section as plain description text, stating this form is specific to video or phone consultations and does not replace the general treatment consent the patient signs separately.
- Add the address and emergency contact as connected or standard Text questions near the top of the form, so reception can see them at a glance if a call needs to be escalated.
- Build each consent statement as its own Checkboxes question with a single option, I understand and agree, matching the pattern used in the clinic's general consent form so a submitted form shows exactly what was agreed to.
- Assign the form to your telehealth or video appointment type so it goes out automatically in the confirmation email, or send it as a one-off to a patient booking their first video consultation outside that flow.
- Set a clinic policy for what reception or the practitioner does if the address or emergency contact fields are left blank, since a video consultation should not proceed without a location on file.
- Test the form as a patient before a real telehealth appointment, submit it, and confirm the address, emergency contact and every checkbox appear against the correct patient record.
AHPRA: The Medical Board of Australia's Guidelines: Telehealth consultations with patients (effective 1 September 2023) ask practitioners to use a private consultation space, confirm the patient's surroundings, and have a process to continue or reschedule if the technology fails. Other National Boards, including the Physiotherapy Board of Australia, apply the same shared Code of conduct expectations for informed consent and privacy to telehealth as to an in-person consultation, which this form gives its own explicit fields for.
Telehealth fails in different ways to an in-person visit
A patient in the clinic cannot lose their internet connection halfway through an assessment, and a practitioner in the room does not need to ask who else might be listening. Video and phone consultations carry a different set of risks: the call drops out, the patient is in a public or shared space without realising the practitioner can hear it, or something happens during the session that needs an in-person response the practitioner cannot give from a screen. A general treatment consent does not cover any of this, which is why telehealth gets its own form rather than a note added to the existing one.
Location and a fallback plan, not just a video link
The two fields that make this form different from a standard consent are the address the patient is attending from and an emergency contact. Neither is needed for an in-person appointment, where the practitioner already knows exactly where the patient is. For a video consultation, capturing that address before the session starts means the practitioner is not trying to establish it under pressure if something goes wrong partway through. The same logic applies to the fallback plan: agreeing in advance what happens if the connection fails, rather than improvising it live, is what the Medical Board's telehealth guidance means by having a process to continue or reschedule.
Recording gets its own, separate agreement
Video consultation software makes recording easy, which is exactly why this form treats it as its own explicit statement rather than folding it into the general consent to treatment. A patient who agrees to a telehealth consultation has not automatically agreed to it being recorded, and this template keeps the two decisions separate, alongside a plain statement that telehealth will not suit every situation and an in-person visit may still be needed.
Sources
- The Medical Board of Australia's Guidelines: Telehealth consultations with patients (effective 1 September 2023) ask practitioners to use a consultation space free from being overheard or overseen by others, confirm the patient's surroundings and who might see or hear the session, have a process in place to continue or reschedule if the technology fails, and record consent from all participants if a consultation is digitally recorded. Medical Board of Australia (Ahpra), checked 25 Sep 2026.
- Cliniko patient form templates are created under Settings > Patient form templates using sections and individual questions, can include connected questions tied to the patient's own record, and can be sent via appointment confirmation emails or as a one-off to an individual patient. Cliniko Help, checked 25 Sep 2026.
- Cliniko supports sending a patient form to an individual patient as a one-off, separate from the automated confirmation and reminder email flow. Cliniko Help, checked 25 Sep 2026.
- The shared Code of conduct for registered health practitioners, applied by each National Board including the Physiotherapy Board of Australia, describes informed consent as covering the proposed treatment, material risks, alternatives, and the patient's right to withdraw consent at any time, regardless of how the consultation is delivered. Physiotherapy Board of Australia, checked 25 Sep 2026.