BOOKINGS · CONTACT FORM TEMPLATE

Doctor Appointment Request Form (Medical Practice)

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.

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form.htmlhtml35 lines

01<form action="https://splitforms.com/api/submit" method="POST">
02  <input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
03  <input type="hidden" name="subject" value="New appointment request">
04 
05  <label for="patient_name">Patient name *</label>
06  <input id="patient_name" type="text" name="patient_name" placeholder="Daniel Chen" required>
07  <label for="email">Email *</label>
08  <input id="email" type="email" name="email" placeholder="patient@example.com" required>
09  <label for="phone">Phone *</label>
10  <input id="phone" type="tel" name="phone" placeholder="+1 415 555 0142" required>
11  <label for="reason">Reason for visit *</label>
12  <select id="reason" name="reason" required>
13    <option value="">Choose…</option>
14    <option>Routine checkup</option>
15    <option>Follow-up</option>
16    <option>New symptoms</option>
17    <option>Prescription refill</option>
18    <option>Other</option>
19  </select>
20  <label for="preferred_date">Preferred date *</label>
21  <input id="preferred_date" type="date" name="preferred_date" required>
22  <label for="symptoms">Symptoms or notes (optional)</label>
23  <textarea id="symptoms" name="symptoms" placeholder="Briefly describe what brings you in."></textarea>
24  <label for="insurance">Insurance provider (optional)</label>
25  <input id="insurance" type="text" name="insurance" placeholder="Blue Cross / Aetna / N/A">
26 
27  <!-- honeypot — bots fill every field -->
28  <input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">
29 
30  <button type="submit">Send</button>
31</form>
32 
33<p style="margin-top:12px;font-size:11px;color:#888;text-align:right">
34  Powered by <a href="https://splitforms.com" style="color:#888;text-decoration:none" target="_blank" rel="noopener">splitforms</a>
35</p>

1,000

submissions / mo, free

fields, ready to ship

code outputs

60s

from copy to inbox

Doctor Appointment Request Form (Medical Practice) — example splitforms template with submissions inbox

§ 01Why it mattersthe qualifying-fields argument

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.

✦ at a glance

→Doctor appointment · 7 fields
→HTML, JS, React, PHP, cURL outputs
→One POST endpoint, no SDK
→Honeypot + classifier, no CAPTCHA

§ 02Live previewinteractive · sandboxed · no key required

See exactly what your visitors see — and you’ll receive.

Left: the rendered form, fully interactive in a sandboxed iframe. Right: the email and dashboard view that lands the moment a visitor submits.

preview · doctor-appointment-formlocalhost:3000

✦ what you’ll see in your inbox

Every submission becomes an email plus a dashboard row. The fields below are the exact payload your form will send. Reply-to is wired to the visitor’s email so hitting reply goes back to them.

dashboard · new submission14ms · 200 OK

SUBJECT · New appointment request

Patient name: Maya Iyer
Email: maya@studio71.co
Phone: +1 415 555 0142
Reason for visit: Routine checkup
Preferred date: 2026-05-15
Symptoms or notes (optional): —
Insurance provider (optional): —

Iframe is sandboxed — submit doesn’t actually fire. Get your access key to wire it up live.

§ 03Three steps3 steps · ~60 seconds

Generate, embed, receive.

Three actions stand between you and your first lead. None of them require a backend, a database, or a CAPTCHA library.

STEP 01GENERATE

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.

Create your form

key=sk_live_••••••••

STEP 02EMBED

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.

snippethtml

<form action="https://splitforms.com/api/submit" method="POST">
  …
</form>

STEP 03RECEIVE

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.

inbox · 1 newjust now

FROM contact@yoursite.com

New appointment request

Maya Iyer maya@studio71.co

Loved your last open house in Hayes — looking for similar with parking. Pre-approved through Wells Fargo.

§ 04Copy & ship5 languages · same endpoint

Five outputs. One backend.

HTML by default. Click open the language you ship in — every variant POSTs to the same /api/submit endpoint.

01HTMLform.html35 lines

<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 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="noopener">splitforms</a>
</p>

02JavaScriptform.js51 lines

<form id="lf-form">
  <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">
  <button type="submit">Send</button>
</form>

<p 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="noopener">splitforms</a>
</p>

<script>
  document.getElementById('lf-form').addEventListener('submit', async (e) => {
    e.preventDefault();
    const data = new FormData(e.target);
    data.set('access_key', 'YOUR_ACCESS_KEY');
    data.set('subject', 'New appointment request');

    const res = await fetch('https://splitforms.com/api/submit', {
      method: 'POST',
      body: data,
      headers: { Accept: 'application/json' },
    });

    const json = await res.json();
    if (json.success) {
      e.target.reset();
      alert('Sent!');
    } else {
      alert('Error: ' + (json.message || 'Try again'));
    }
  });
</script>

03React / Next.jsForm.tsx66 lines

'use client';

import { useState, type FormEvent } from 'react';

export default function DoctorForm() {
  const [status, setStatus] = useState<'idle' | 'sending' | 'sent' | 'error'>('idle');

  async function onSubmit(e: FormEvent<HTMLFormElement>) {
    e.preventDefault();
    setStatus('sending');

    const data = new FormData(e.currentTarget);
    data.set('access_key', 'YOUR_ACCESS_KEY');
    data.set('subject', 'New appointment request');

    const res = await fetch('https://splitforms.com/api/submit', {
      method: 'POST',
      body: data,
      headers: { Accept: 'application/json' },
    });

    const json = await res.json();
    setStatus(json.success ? 'sent' : 'error');
    if (json.success) e.currentTarget.reset();
  }

  if (status === 'sent') return <p>Thanks — we&rsquo;ll be in touch.</p>;

  return (
    <>
    <form onSubmit={onSubmit}>
      <label htmlFor="patient_name">Patient name *</label>
      <input id="patient_name" type="text" name="patient_name" placeholder="Daniel Chen" required />
      <label htmlFor="email">Email *</label>
      <input id="email" type="email" name="email" placeholder="patient@example.com" required />
      <label htmlFor="phone">Phone *</label>
      <input id="phone" type="tel" name="phone" placeholder="+1 415 555 0142" required />
      <label htmlFor="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 htmlFor="preferred_date">Preferred date *</label>
      <input id="preferred_date" type="date" name="preferred_date" required />
      <label htmlFor="symptoms">Symptoms or notes (optional)</label>
      <textarea id="symptoms" name="symptoms" placeholder="Briefly describe what brings you in." />
      <label htmlFor="insurance">Insurance provider (optional)</label>
      <input id="insurance" type="text" name="insurance" placeholder="Blue Cross / Aetna / N/A" />

      <button type="submit" disabled={status === 'sending'}>
        {status === 'sending' ? 'Sending…' : 'Send'}
      </button>

      {status === 'error' && <p>Something went wrong. Try again.</p>}
    </form>

      <p style={{ marginTop: 12, fontSize: 11, color: '#888', textAlign: 'right' }}>
        Powered by <a href="https://splitforms.com" target="_blank" rel="noopener" style={{ color: '#888', textDecoration: 'none' }}>splitforms</a>
      </p>
    </>
  );
}

04PHPsubmit.php28 lines

<?php
// Drop into a PHP page. Receives a form POST and proxies it to splitforms.com.
// Useful when you want to add server-side validation or rate limiting.

if ($_SERVER['REQUEST_METHOD'] === 'POST') {
    $allowed = ['patient_name', 'email', 'phone', 'reason', 'preferred_date', 'symptoms', 'insurance'];
    $payload = ['access_key' => 'YOUR_ACCESS_KEY'];
    $payload['subject'] = 'New appointment request';

    foreach ($allowed as $f) {
        if (isset($_POST[$f])) $payload[$f] = $_POST[$f];
    }

    $ch = curl_init('https://splitforms.com/api/submit');
    curl_setopt($ch, CURLOPT_POST, true);
    curl_setopt($ch, CURLOPT_POSTFIELDS, http_build_query($payload));
    curl_setopt($ch, CURLOPT_RETURNTRANSFER, true);
    curl_setopt($ch, CURLOPT_HTTPHEADER, ['Accept: application/json']);
    $response = curl_exec($ch);
    $status   = curl_getinfo($ch, CURLINFO_HTTP_CODE);
    curl_close($ch);

    header('Content-Type: application/json');
    http_response_code($status);
    echo $response;
    exit;
}
?>

05cURLtest.sh11 lines

curl -X POST https://splitforms.com/api/submit \
  -H "Accept: application/json" \
  -d "access_key=YOUR_ACCESS_KEY" \
  -d "subject=New appointment request" \
  -d "patient_name=Jane Builder" \
  -d "email=jane@example.com" \
  -d "phone=+15555555555" \
  -d "reason=Routine checkup" \
  -d "preferred_date=2026-05-15" \
  -d "symptoms=Hello from cURL" \
  -d "insurance=Jane Builder"

Replace YOUR_ACCESS_KEY with the key from your dashboard. That’s the only edit.

§ 04bUse this template with…17 frameworks · same backend

One template. Every framework.

The same field set works on every framework splitforms supports. HTML, React, Next.js, Vue, Astro, Hugo, WordPress — same POST, same backend.

§ 06FAQ4 answered

Things people ask before they ship.

Direct answers, no marketing fluff. Missing one? Email hello@splitforms.com.

01Is 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.

02Can 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.

03How 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.

04What 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.

✻ ✻ ✻

Ship your doctor appointment request form (medical practice) in 60 seconds.

1,000 free submissions per month. No credit card. Copy the snippet, paste your access key, watch leads land in your inbox.

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v0.1 · founders pricing locked in · early access open