Parental Consent for Telehealth

Specialties School

Updated:   Published

Does anyone have an existing consent form for telehealth appointments?  I am in a high school so I am anticipating students doing telehealth during school hours is going to become more common.  

I've been working on creating one and this is what I have so far. Any input is appreciated! 

Parental Authorization:

Student Telehealth Appointment During School Hours

Student Name: ____________________­­­­­­­­­

Student Number: __________________

Date and Time of Appointment: __________________

Name of Provider: ______________________________

My student has a scheduled telehealth appointment and I am requesting that XXXX provide a private and confidential space for this appointment.  I will provide all equipment necessary for my student to attend the appointment including laptop with camera, phone, and headphones.  I understand that XXXX staff cannot enforce student participation in a telehealth appointment, nor are they responsible for connectivity issues that may arise during the session.  I will hold XXXX and its staff harmless for an incomplete or interrupted session, or in a breech in confidentiality during the session. 

I understand that that some therapies may not be as effective in this setting/context and that I need to be available during the appointment to communicate with the provider as needed.  XXXX  staff will not participate in the appointment, nor provide consent.

I hereby release all claims, demands, damages, actions, causes of action or suits of law or inequity, of whatsoever or nature against XXXX the School Board or any employees following this request.

I understand that I am signing on behalf of a minor or otherwise legally dependent person, and I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.

Signature of Parent(s) or Guardian(s): ___________________

*Date of Request:  ________________
*Request must be 72 hours prior to appointment

Approval: __________

Date: ______________

Staff member to supervise appointment: _________________

Location of appointment: _______________________________

Flare, ASN, BSN

4,431 Posts

Specializes in school nursing, ortho, trauma.

looks like a good form.  What are you using the telehealth visits for?  Student illness concerns? Mental health? I find the concept interesting, but I couldn't figure out how to effectively utilize.  

Specializes in Geriatric Home Health, High School Nurse.
2 minutes ago, Flare said:

What are you using the telehealth visits for? 

I just had a parent request for a space for their child to do a mental health visit during school hours.  We as a school had nothing to do with the appointment, but I facilitated the visit by providing a private space.  I foresee more of these types of things coming since telehealth is becoming so prevalent, so I want to make sure we are prepared with a process and a consent form so that the school isn't held responsible.

Specializes in School Health.

The form looks nice. Here at my school, the parents choose to pull the student out for the telehealth appt and have the appt in the car and then bring the student back inside.


7,736 Posts

Specializes in retired LTC.

Maybe you could run your form past your school's legal consultant? Or might that just open up the proverbial 'can of worms' for you?

Specializes in Geriatric Home Health, High School Nurse.
19 hours ago, amoLucia said:

Maybe you could run your form past your school's legal consultant

I submitted it to admin and they are taking it to the board and school lawyer for review.  

Thanks for all the input, everyone!

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