3 minutes to complete
To complete the HIPAA Consent for Telehealth Form, you must be a patient or legal guardian of a patient receiving telehealth services. You must also have the capacity to consent to treatment and understand the risks and benefits of telehealth.
Do you understand that telehealth involves the use of secure video, audio, or electronic communication to deliver healthcare services?
Do you acknowledge that telehealth sessions will be conducted using HIPAA-compliant technology to protect your privacy?
Do you understand that despite security measures, there are risks such as technical failures or potential unauthorized access to electronic data?
Do you agree that you may choose to stop telehealth services at any time and request in-person care instead?
Do you consent to your health information being used and disclosed for treatment, payment, and healthcare operations under HIPAA rules?
Do you agree to provide your current location at the start of each telehealth session in case of emergency?
Emergency Phone Number
Do you understand that you have the same privacy rights during telehealth sessions as you do in person?
Do you agree not to record telehealth sessions without prior written consent from your provider?
Patient Signature
BlockSurvey puts privacy and security above anything else. The use of end-to-end encryption is not a gimmick as in many products; it's a core feature enabling privacy and security. The survey building tools are impeccable. I've used numerous SaaS survey tools, and nothing comes close.
This platform goes far beyond basic surveys. I’ve used it for lead generation, landing page enrichment, and even embedded videos. Everything’s easy to use, well documented, and super flexible—whether you're building forms, quizzes, or something more advanced.
Uses end-to-end encryption technology that allows users to create survey forms where data is secure and private. UI looks very beautiful.
For our NGO, data privacy is everything—and this platform nails it. It keeps personal info fully protected while letting us design beautiful, chat-like surveys that increase engagement. Team collaboration features sealed the deal.
From end-to-end encryption-level security and AI-generated questions to powerful logic flows and white-label domains, BlockSurvey has it all. It’s secure, innovative, and packed with features like calculations, templates, and in-app analytics. I use it to create personalized assessments for leadership training—nothing else compares.
BlockSurvey is very user-friendly with amazing customization options. It makes capturing data simple and secure. While the Web3 space still has room to mature, the platform itself is smooth and intuitive.
Creating surveys with BlockSurvey has been a breeze. The drag-and-drop interface is intuitive, and we’re able to collect data anonymously and securely—without intermediaries. It’s interactive, friendly, and encourages high participation while protecting user privacy. The reports are solid, and we’ve used it confidently for internal and external feedback.
Few tools combine data confidentiality and form aesthetics like this one. The conversational design improved my response rate by 43%, and the webhook integrations made syncing to our CRM effortless. I also love how responsive and community-driven the support team is.
I think BlockSurvey is good for short and long surveys. What I find the best is the fact that there are so many templates I can use and customize.
