The form includes information about the risks, benefits, and responsibilities of telehealth, as well as the signature of the patient or legal representative AHRQ has created a sample telehealth consent form (Word,KB) that is easy to understand. Prior to your telehealth visit, please read the below consent for telehealth treatmentYou retain the option to withhold or withdraw consent at any time without affecting your TELEHEALTH INFORMED CONSENT. The form includes language for healthcare provider