Telehealth Technical Readiness Check

Telehealth Technical Readiness Check — Form Fields

This healthcare template includes 15 fields. Pre-appointment form to verify patient technical readiness for telehealth visits. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Email (email, required)
• Phone Number (text, required)
• Appointment Date and Time (text, required)
• Provider Name (text, required)
• Device for Visit (dropdown selection, required) — options: Smartphone, Tablet, Laptop, Desktop Computer
• Operating System (dropdown selection, optional) — options: iOS (iPhone/iPad), Android, Windows, Mac, Chromebook
• Camera Working (multiple choice, required) — options: Yes, No, Unsure
• Microphone Working (multiple choice, required) — options: Yes, No, Unsure
• Internet Connection (dropdown selection, required) — options: WiFi, Cellular Data, Wired Ethernet
• Tested Video Platform Before (multiple choice, required) — options: Yes, No
• Video Platform (dropdown selection, required) — options: Zoom, Doxy.me, MyChart Video, Teams, Other
• Private Quiet Space Available (multiple choice, required) — options: Yes, No
• Need Technical Help Before Appointment (multiple choice, required) — options: Yes, No
• Specific Technical Concerns (long text, optional)