Capture the clinical basics
Injury / pain area dropdown (back, neck, shoulder, knee, hip, post-surgical, other), how long it's been going on, referral status (have one / need one / not sure), insurance carrier, preferred days.
Form template · Doctor appointment
Physical Therapy Contact Form Template
A new PT patient is usually in pain today and choosing between three clinics' websites. The clinic whose form asks the right four questions — and whose front desk calls back first — gets the plan-of-care.
- 500 free total
- 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
This template is one of our free HTML form templates. See more form templates by industry.
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Every template is free and fully editable in the drag-drop builder — swap fields, colors, and the button label before you publish.
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No backend code
No server, API route, or SDK — your Physical Therapy 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 Physical Therapy Contact Form snippet, swap in your access key, and ship.
Copy and ship
Your Physical Therapy 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 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="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 this form to your site.
To add a Physical Therapy 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.
Verify benefits before the callback
The insurance field lets your front desk run verification before dialing. The callback becomes 'you're covered with a $30 copay, can you come Thursday?' — which books at far higher rates than 'we'll check and call you back'.
Book the eval same week
Webhook new requests to the front-desk inbox or your EMR via Zapier (WebPT, Prompt, Clinicient all accept inbound leads). Patients in pain book with whoever offers the first eval slot — be that clinic.
What's included
What's included.
PT clinics live and die on new-patient volume and plan-of-care completion, and both start at the website form. The request form needs injury area, how it happened, referral status, and insurance carrier — because direct access rules and insurance requirements vary by state and plan, and your front desk needs to know whether to verify benefits or request the referral before the eval. A same-day callback with 'you're verified, come in Thursday' is how a website visit becomes a 12-visit plan of care. Referral status + insurance captured up front — front desk verifies before the callback.
- 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 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 payment forms →Need time slots? Online booking →Questions
Frequently asked questions.
View all FAQsIs this form HIPAA-compliant?
No. splitforms is not HIPAA compliant and signs no BAA on any plan. The form collects scheduling information — contact details, body area, insurance carrier — not treatment records or diagnoses. Submissions are encrypted in transit and at rest, and you can delete them on request. Detailed medical history belongs in your EMR intake packet after the appointment is booked, not on the website.
Do patients need a referral before requesting an appointment?
Depends on your state's direct-access rules and the patient's insurance. That's exactly why the form asks referral status as a dropdown — 'I have one' leads get booked immediately; 'I need one' leads get your front desk's guidance on getting it. Neither lead is lost.
Can this feed WebPT or our EMR?
Yes — webhook the submission JSON via Zapier into WebPT, Prompt, Clinicient, or any system with an inbound API. The new-patient record arrives with injury area, referral status, and insurance pre-filled, so the front desk starts verification instead of data entry.
Should cash-pay and insurance patients use the same form?
Yes — add a 'how do you plan to pay?' dropdown with insurance / cash-pay / workers' comp / auto claim options. Each routes differently (verification vs. price quote vs. adjuster paperwork), and the form sorting them saves the front desk a phone-tag cycle on every lead.
How fast should we respond to a new-patient request?
Same business day, ideally within the hour. PT patients are typically in active pain and contact 2-3 clinics at once — first eval offered usually wins. Webhook the form to the front-desk Slack or an SMS so requests don't sit in email.
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 per month
- 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 per month, billed yearly
Every Pro feature with triple the volume — $0.27 per 1,000 at full use.
- 15,000 submissions per month
- 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