A telemedicine e-visit request form is used by patients to submit requests for e-visits from their telehealth providers. If you provide telemedicine services, this free Telemedicine E-visit Request Form makes it easier for you to accept and organize online requests for virtual appointments. To get started, just customize the form to meet your needs and embed it on your website or send the form link via email or message. Patients can provide their personal information, select whether they’d like a phone, email, or video appointment, describe their medical history and insurance details, read your terms and conditions, and complete the form with their electronic signature. Submissions will be stored in your secure Jotform account, which can be further enhanced by our HIPAA compliance features if you have a Gold plan.
Since no two telehealth providers are the same, use our drag-and-drop Form Builder to customize this Telemedicine E-visit Request Form for your practice. Add form fields, change the terms and conditions, and integrate the form with other apps you rely on — such as your cloud storage accounts or healthcare CRM — to automatically sync submissions data to those accounts. You can even add a dropdown calendar that lets patients enter dates for their appointments and add them as events to Google Calendar automatically! Schedule and monitor e-visits more easily with our Telemedicine E-visit Request Form and get patients the care they need as quickly as possible.