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Forms & Surveys

FormsTelemedicine involves the use of electronic communication to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up, recording  and/or education. This page contains common forms that are used to seek patient consent prior to a consultation being performed over the Utah Telehealth Network. For further assistance regarding the forms on this page, please contact the Utah Telehealth Network.

Patient Consent Forms

This following forms are required if a patient requires a general or specialty consultation conducted over the Utah Telehealth Network. The appropriate form must be completed and submitted prior to any consultation.

Permisson To Record Forms

The following forms are required if the Utah Telehealth Network is seeking consent to record a presentation or patient consultation. The appropriate form must be completed and submitted prior to any recording.