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 total
- No PHP · no SDK
- One POST endpoint
Live template preview
Doctor appointment
Patient name *Daniel Chen
Email *[email protected]
Phone *+1 415 555 0142
Reason for visit *Routine checkup
Preferred date *
+ 2 more fields in the builder
Send
This template is one of our free HTML form templates. See more form templates by industry.
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 *[email protected]
Phone *+1 415 555 0142
+ 4 more fields in the builder
Send
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Email *[email protected]
Phone *+1 555 0142
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Veterinary appointment
Owner name *Sofia Reis
Email *[email protected]
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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="[email protected]" 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>
<!-- 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 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 spam scoring, 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 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
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
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