Resident and family consent form for virtual care
A plain-English, ready-to-adapt consent form for virtual care.
What this is: a plain-English consent form your home can adapt and use with residents.
Who it's for: nurse managers and care staff arranging virtual care consultations; residents and their families or representatives.
How to use this template. Replace every
[square bracket]with your home's details. Review it against your own consent and privacy policies before use. Keep a signed copy in the resident's record. This is a general template, not legal advice; have your organisation review it before adopting it.
Virtual care consultation: information and consent
What is virtual care?
Virtual care means using secure video, and sometimes phone, together with clinical equipment, to connect with a doctor, specialist or allied health professional, without you or the practitioner having to travel. Most consultations use video so the practitioner can see you clearly. Phone may be used if video isn't possible.
What does a virtual care consultation involve?
- Your home provides the equipment: a screen, camera, microphone and a reliable internet connection, set up and supported by trained staff.
- [Insert home/organisation name] covers the cost of the equipment and the platform used for your consultation.
- You'll use a quiet, private space so your consultation stays confidential.
- A staff member can stay with you to help, if you'd like, or you can choose to have the consultation privately.
- Your family member or representative can join if you wish.
Your rights and choices
- Virtual care is your choice. You can ask for an in-person visit instead, and you can change your mind at any time.
- Choosing virtual care, or choosing not to, will never affect the quality of care you receive.
- Your privacy, dignity and cultural preferences are respected at every step.
- You can ask questions at any time, before, during or after a consultation.
How your information is protected
- Consultations use secure, encrypted technology.
- Only the people involved in your care take part.
- Information shared during the consultation is recorded in your health record, the same as an in-person visit.
- Your information is handled in line with the Privacy Act and [insert home/organisation name]'s privacy policy.
Recordings
Consultations are not recorded unless you are told in advance and give specific consent. If a recording is ever proposed, staff will explain why and ask for your permission first.
Consent
Please read, or have a staff member read with you, and complete the section below.
I confirm that:
- □ Virtual care has been explained to me, and I have had the chance to ask questions.
- □ I understand I can choose an in-person visit instead, and can change my mind at any time.
- □ I understand how my information will be used, shared and protected.
- □ I agree to take part in virtual care consultations as part of my care.
Who may be present or involved (tick all that apply):
- □ A staff member to assist me
- □ My family member or representative:
[name and relationship] - □ An interpreter, if needed:
[language]
| Field | Details |
|---|---|
| Resident name | [ ] |
| Signature | [ ] |
| Date | [ ] |
| If signed by a representative — name | [ ] |
| Relationship to resident | [ ] |
| Authority to consent (e.g. guardian, EPOA) | [ ] |
| Staff member witnessing | [ ] |
| Staff signature and date | [ ] |
Withdrawing consent
You can withdraw your consent at any time. Just tell any staff member. We'll update your record and arrange an alternative where one is needed. Withdrawing consent will not affect your care.
Need help?
- Questions about virtual care in our home:
[insert home contact] - Visionflex support and training:
[insert Visionflex support contact]
Visionflex is ISO 27001 and ISO 13485 certified.
Visionflex acknowledges the Traditional Custodians of Country throughout Australia and pays respect to Elders past, present and emerging.