Capture reason and insurance
Required: reason for visit (cleaning / exam / emergency / cosmetic / ortho / kids), insurance carrier (or 'I'll pay out of pocket'), preferred date window.
Form template · Dental appointment
Dentist Contact Form Template
Dental appointment requests need insurance, preferred date, and reason for visit — without those three, the front desk's morning is back-and-forth phone tag.
- 500 free / mo
- No PHP · no SDK
- One POST endpoint
Live template preview
Dental appointment
Patient name *Daniel Chen
Email *[email protected]
Phone *+1 555 0142
New or existing patient? *New patient
Reason for visit *Routine cleaning + checkup
+ 4 more fields in the builder
Send
Pick your dentist contact form — one click to use it
Every template is free and fully editable in the drag-drop builder — swap fields, colors, and the button label before you publish.
Best matchUse this template
Dental appointment
Patient name *Daniel Chen
Email *[email protected]
Phone *+1 555 0142
+ 6 more fields in the builder
Send
Veterinary appointment
Owner name *Sofia Reis
Email *[email protected]
Phone *+1 555 0142
+ 7 more fields in the builder
Send
Doctor appointment
Patient name *Daniel Chen
Email *[email protected]
Phone *+1 415 555 0142
+ 4 more fields in the builder
Send
No backend code
No server, API route, or SDK — your Dentist Contact Form posts straight to one endpoint.
Straight to your inbox
Every submission is emailed to you and saved to a searchable dashboard — spam filtered before it reaches you.
Copy-paste ready
It's plain HTML you own — paste the Dentist Contact Form snippet, swap in your access key, and ship.
Copy and ship
Your Dentist Contact Form, ready to paste.
HTML by default — the same field set also renders as React, Next.js, PHP, and cURL in your dashboard. Every variant posts to the same /api/submit endpoint. Replace YOUR_ACCESS_KEY with the key from your dashboard; that's the only edit.
<form action="https://splitforms.com/api/submit" method="POST">
<input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
<input type="hidden" name="subject" value="New dental appointment request">
<label for="patient_name">Patient name *</label>
<input id="patient_name" type="text" name="patient_name" placeholder="Daniel Chen" required>
<label for="email">Email *</label>
<input id="email" type="email" name="email" placeholder="[email protected]" required>
<label for="phone">Phone *</label>
<input id="phone" type="tel" name="phone" placeholder="+1 555 0142" required>
<label for="patient_type">New or existing patient? *</label>
<select id="patient_type" name="patient_type" required>
<option value="">Choose…</option>
<option>New patient</option>
<option>Existing patient</option>
</select>
<label for="reason">Reason for visit *</label>
<select id="reason" name="reason" required>
<option value="">Choose…</option>
<option>Routine cleaning + checkup</option>
<option>Toothache / pain</option>
<option>Cosmetic (whitening, veneers)</option>
<option>Cavity / filling</option>
<option>Crown or bridge</option>
<option>Implants consultation</option>
<option>Emergency</option>
<option>Other</option>
</select>
<label for="preferred_date">Preferred date *</label>
<input id="preferred_date" type="date" name="preferred_date" required>
<label for="last_visit">Last dental visit</label>
<select id="last_visit" name="last_visit">
<option value="">Choose…</option>
<option>Within 6 months</option>
<option>6–12 months</option>
<option>1–2 years ago</option>
<option>2+ years ago</option>
<option>First time</option>
</select>
<label for="insurance">Insurance provider</label>
<input id="insurance" type="text" name="insurance" placeholder="Delta Dental / Cigna / N/A">
<label for="notes">Anything we should know?</label>
<textarea id="notes" name="notes" placeholder="Anxiety, allergies, ongoing treatment elsewhere."></textarea>
<!-- honeypot — bots fill every field -->
<input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">
<button type="submit">Send</button>
</form><p class="splitforms-attribution" style="margin-top:12px;font-size:11px;color:#888;text-align:right">
Powered by <a href="https://splitforms.com" style="color:#888;text-decoration:none" target="_blank" rel="sponsored noopener">splitforms</a>
</p>How to add it
How to add a Dentist Contact Form to your site.
To add a Dentist Contact Form to your site you need three things: a free splitforms access key, the HTML snippet above, and your key pasted into it. No backend, database, or CAPTCHA library — the form posts to one URL and every submission lands in your inbox and dashboard.
Triage emergencies
Emergency-flagged submissions trigger an SMS to the on-call dentist or front desk via Twilio. 'Severe pain' or 'broken tooth' gets called back within the hour, not the next morning.
Verify insurance ahead of visit
Insurance carrier and member ID (optional) lets the front desk verify benefits before the appointment. New patients arrive with paperwork pre-done; chair time is for dentistry, not admin.
What's included
What's in this Dentist Contact Form template?
Dental front-desk staff spend a third of their day on phone tag — calling insurance, calling the patient back, scheduling around hygienist availability. A form that captures insurance carrier, preferred date window, and reason for visit removes most of that. Emergency leads (broken tooth, severe pain) get triaged to today; cleaning and exam requests fit into the 6-week-out hygiene book; cosmetic and ortho consults route to the appropriate specialist. Same form, three completely different scheduling paths. BAA available on Pro · webhooks into Dentrix / Eaglesoft / Open Dental.
- Dental appointment — 9 ready-made fields
- HTML, JS, React, PHP, and cURL outputs
- One POST endpoint, no SDK — honeypot and classifier, no CAPTCHA
Where submissions go
Where do your Dentist Contact Form submissions go?
Reply-to is wired to the visitor's email, so one tap on Reply answers them directly — while the built-in honeypot and spam classifier filter out bots before they reach you. Every submission is emailed to your inbox and can forward to a webhook or Slack the moment a visitor hits send.
- Reply-to wired to the visitor's email — reply straight from your inbox
- Honeypot and spam classifier filter bots, no CAPTCHA friction
- Live dashboard, CSV export, and signed webhooks on paid plans
How SplitForms works
From form to workflow in 3 simple steps.
Connect your form, collect every submission, and send data where it needs to go — without building backend infrastructure.
Add your endpoint
Point your form to your unique SplitForms endpoint. That's it.
Receive submissions
We instantly capture and organize every submission in your inbox.
Route anywhere
Send data to email, spreadsheets, CRMs, webhooks, and 7,000+ apps.
No credit card required. Set up in under 60 seconds.
Connect & automate
Connect your favorite tools and automate everything
SplitForms works with the destinations you route to and the platforms you build on — from Slack and Sheets to WordPress, Shopify, and Next.js. And with Stripe connected, your forms can take payments too.
NewTake payments on your formsDeposits, bookings, order forms — submitters check out through Stripe and the money goes straight to your Stripe account. Included on every paid plan.See plans →Trusted by indie teams and agencies shipping forms worldwide
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Testimonials
Loved by developers shipping at every scale.
40 quotes on record — from indie hacks to agency migrations.
“I replaced a Lambda + DynamoDB + SES contact form with six lines of HTML. It took eleven minutes, and the dashboard is better than what I was going to build.”
“We migrated 14 client sites off Formspree in a single weekend. The price is a third of what we paid, the API is more honest, and the spam filter actually works.”
“The webhook payload is signed, idempotent, and well-shaped. It reads like code from a competent team, not a CRUD app held together with duct tape.”
“I stopped reaching for Typeform on small marketing sites. splitforms covers 90% of the use case at none of the bloat.”
“I onboarded our whole agency in an afternoon. The MCP integration meant Cursor literally dropped the form straight into our client repos for us.”
“The free plan gave me 500 submissions before I paid a cent, and Pro is five dollars a month. I've spent more on coffee deciding which backend to use.”
“Spam went from forty junk entries a day to zero, with no reCAPTCHA puzzle ruining the form. The honeypot and time-trap just quietly do their job.”
“Point the form action at one endpoint and you're done. No SDK, no client library, no build step. This is how a form backend should feel.”
“Leads land in Slack the second someone submits, and a copy goes to Google Sheets for the sales team. I wired both up in under ten minutes.”
“I run a static Hugo site on a five-dollar VPS. splitforms gave it a real contact form without me standing up a single server.”
Questions
Dentist Contact Form questions.
View all FAQsIs this HIPAA compliant?
splitforms encrypts submissions at rest and in transit. For full HIPAA coverage you also need a BAA — available on the Pro plan with a separate request. Don't put diagnosis details on the form; capture intent and book the call. Real PHI lives in your dental software, not in form storage.
Can I integrate with Dentrix / Eaglesoft / Open Dental?
Yes — webhook the JSON. Most practice management software accepts inbound webhooks via Zapier or Open Dental's HL7 module. Lead lands in your scheduling app pre-filled.
What about new-patient paperwork?
Auto-respond to new-patient submissions with a link to your full intake forms (medical history, consent). Patient fills them out before the visit; chair time is for the dentist, not admin. Most practices see 30+ minutes saved per new patient.
How do emergencies actually reach the dentist after hours?
Webhook to Twilio with a routing rule — 'emergency' submissions trigger a call to the on-call number. After-hours emergency calls are usually 1-2 a week and the patient is grateful to reach a human.
Simple pricing
Start free. Scale when you need more.
Choose a plan that fits your workflow — from a free form endpoint to full automations, exports, Stripe payments, and higher submission limits.
Free
$0
For side projects and indie devs.
- 500 submissions / mo
- Unlimited forms
- Email notifications included
- Honeypot spam filtering
- Submissions dashboard
- MCP setup stays free
- No credit card required
Most Popular
Pro
$5/ month
was $15 · save 67% · new-user price
For agencies and growing products.
- 5,000 submissions / mo
- Unlimited forms
- Stripe payments on your forms
- Every paid feature included
- Priority support (under 4hr)
- 10× free submission volume
- Cancel anytime
Pre-launch · founders pricing locked in
3-Year
$59/ first 3 years
was $99 · save 40% · new-user price
Pay $59. 3 years sorted.
- 15,000 submissions / mo
- Unlimited forms
- Everything in Pro
- $59 for 3 years, then $59/year
- Long-term discount
- Priority support included
- Vote on the roadmap
No credit card required on Free • Cancel anytime