Capture patient and reason
Required: name, DOB, new vs existing patient, reason for visit, preferred date window, best phone. Optional: insurance carrier, current medications, referring physician.
Form template · Doctor appointment
Doctor Appointment Form Template
Doctor offices field 30-50 appointment-request calls a day. The form takes the routine ones (checkup, follow-up, prescription refill) off the phone queue so reception can focus on the urgent calls.
- 500 free / mo
- No PHP · no SDK
- One POST endpoint
Live template preview
Doctor appointment
Patient name *Daniel Chen
Email *patient@example.com
Phone *+1 415 555 0142
Reason for visit *Routine checkup
Preferred date *
+ 2 more fields in the builder
Send
Pick your doctor appointment 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
Doctor appointment
Patient name *Daniel Chen
Email *patient@example.com
Phone *+1 415 555 0142
+ 4 more fields in the builder
Send
Dental appointment
Patient name *Daniel Chen
Email *daniel@example.com
Phone *+1 555 0142
+ 6 more fields in the builder
Send
Veterinary appointment
Owner name *Sofia Reis
Email *sofia@example.com
Phone *+1 555 0142
+ 7 more fields in the builder
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No backend code
No server, API route, or SDK — your Doctor Appointment 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 Doctor Appointment Form snippet, swap in your access key, and ship.
Copy and ship
Your Doctor Appointment 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 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="patient@example.com" required>
<label for="phone">Phone *</label>
<input id="phone" type="tel" name="phone" placeholder="+1 415 555 0142" required>
<label for="reason">Reason for visit *</label>
<select id="reason" name="reason" required>
<option value="">Choose…</option>
<option>Routine checkup</option>
<option>Follow-up</option>
<option>New symptoms</option>
<option>Prescription refill</option>
<option>Other</option>
</select>
<label for="preferred_date">Preferred date *</label>
<input id="preferred_date" type="date" name="preferred_date" required>
<label for="symptoms">Symptoms or notes (optional)</label>
<textarea id="symptoms" name="symptoms" placeholder="Briefly describe what brings you in."></textarea>
<label for="insurance">Insurance provider (optional)</label>
<input id="insurance" type="text" name="insurance" placeholder="Blue Cross / Aetna / N/A">
<!-- 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 Doctor Appointment Form to your site.
To add a Doctor Appointment 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.
Verify insurance
Capture insurance carrier and policy / member ID. Front desk runs eligibility before scheduling — surprise denials at the visit damage the patient relationship. Most EHR systems (Epic, Athena, eClinicalWorks) accept eligibility checks via webhook.
Confirm via SMS
Webhook to Twilio — patient gets a text within hours confirming the slot, or offering alternatives. Reception adds to the EHR scheduling module from the form data.
What's included
What's in this Doctor Appointment Form template?
Doctor offices — primary care, specialty practices, urgent care — handle 30-50 appointment-request calls a day, plus another 30-50 for prescription refills, referrals, and insurance questions. The phone queue eats reception staff. The appointment form captures new vs existing patient, reason for visit, insurance carrier, preferred date / time window, and best contact phone. Reception schedules from the form during slow stretches instead of rushing the calls. New-patient inquiries also need insurance verification before the visit — capturing carrier and policy number upfront lets the office check eligibility before the appointment, which saves billing rework. Webhooks into Athena / DrChrono / eClinicalWorks · NOT HIPAA-compliant out of the box.
- Doctor appointment — 7 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 Doctor Appointment 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
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Questions
Doctor Appointment Form questions.
View all FAQsIs this HIPAA-compliant for collecting PHI?
splitforms is not HIPAA-compliant out of the box — the standard plan doesn't ship a BAA. For real PHI (medical history, diagnoses, treatment), use a HIPAA-compliant form provider (JotForm HIPAA tier, Formstack Healthcare, Paubox Forms). The splitforms form is fine for appointment-request basics (name, phone, reason) but should not collect detailed medical history. Consult your HIPAA security officer.
Can I integrate with Athena / Epic / eClinicalWorks / DrChrono?
Most EHRs accept inbound webhooks via Zapier or HL7 / FHIR APIs. Athena and DrChrono have direct API access; Epic typically requires a vendor integration. The form's JSON maps to the EHR's appointment-request fields. Confirm with your EHR vendor before deploying.
How do I handle prescription refill requests?
Add a 'reason for visit' option of 'prescription refill'. Most practices route refill requests to the nurse / MA queue, not the appointment scheduler. Webhook branches on this field to the right team. Alternatively, route refills to the patient portal directly — federal law (CARES Act) requires patient portal access for clinical communication.
What about same-day / urgent appointments?
Add an urgency field. Same-day requests should still go via phone — the form is not for emergencies. The form's auto-responder should explicitly say 'for medical emergencies, call 911 or your nearest urgent care'. Liability requires that disclaimer prominently.
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, and higher submission limits.
Free
$0
Free forever
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
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Pro
$5/ month
was $15 · save 67% · new-user price
For agencies and growing products.
- 5,000 submissions / mo
- Unlimited forms
- Every paid feature included
- Priority support (under 4hr)
- 10× free submission volume
- Cancel anytime
Pre-launch · founders pricing locked in
3-Year
$59/ 36 months
was $99 · save 40% · new-user price
Pay $59. 3 years sorted.
- 15,000 submissions / mo
- Unlimited forms
- Everything in Pro
- Renews every 3 years
- Long-term discount
- Priority support included
- Vote on the roadmap
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