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 total
- 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
This template is one of our free HTML form templates. See more form templates by industry.
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>
<!-- drop-off analytics + partial leads (the form works without it) -->
<script src="https://splitforms.com/embed.js" async></script>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 spam scoring, 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 automatic spam scoring 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 automatic spam scoring filter bots, no CAPTCHA friction
- Live dashboard, CSV export, and signed webhooks on paid plans
How SplitForms works
What happens after someone submits your form?
splitforms receives the submission, filters spam, saves it to your dashboard and emails you — then, on paid plans, sends it on to your webhooks and integrations. No backend infrastructure to build.
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
Where can submissions go besides email?
On paid plans, submissions can also go to Slack, Discord, Google Sheets, Notion, Airtable, Zapier or any signed webhook — and splitforms works on the platforms you build on, from WordPress and Shopify to Next.js. 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 →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
How much does splitforms cost?
Free gives you 500 submissions for $0 — no card, no time limit. Pro is $5/month for 5,000 submissions a month, and Annual is $49/year for 15,000 a month with every Pro feature.
Free
$0— 500 submissions
For side projects and indie devs.
- 500 free submissions
- Unlimited forms
- Email notifications included
- Smart spam filtering
- Submissions dashboard
- Redirect after submit
- MCP server included
Recommended
Pro
$5/ month
Billed monthly
Every paid feature, for agencies and growing products.
- 5,000 submissions / mo
- Unlimited forms
- Webhooks and integrations
- CC/BCC, auto-replies and routing
- File uploads with 500 MB storage
- Stripe payments on your forms
- 3 team seats
- Cancel anytime
Annual
$49/ year
About $4.08/mo, billed yearly
Every Pro feature with triple the volume — $0.27 per 1,000 at full use.
- 15,000 submissions / mo
- Unlimited forms
- Everything in Pro
- File uploads with 5 GB storage
- 3 team seats
- Priority email support
No credit card required on Free • Cancel anytime • Full pricing and FAQ