Patient Telehealth Privacy Preference Form
Patient Name
Date of Birth
Contact Email
Contact Phone
Telehealth Session Privacy Preferences
Please indicate your preferences regarding your telehealth sessions.
I prefer sessions in a private location.
I prefer audio-only sessions (no video).
I consent to having my session recorded.
I permit family members or caregivers to be present during my sessions.
Additional Privacy Requests
Patient Acknowledgement
Patient Signature
Date