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 / 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 physical therapy 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
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
Personal trainer free trial
Full name *Hans Becker
Email *hans@example.com
Phone *+1 555 0142
+ 5 more fields in the builder
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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="sponsored noopener">splitforms</a>
</p>How to add it
How to add a Physical Therapy Contact 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 in this Physical Therapy Contact Form template?
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 classifier, no CAPTCHA
Where submissions go
Where do your Physical Therapy 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 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
How SplitForms works
From form to workflow in 3 simple steps.
Connect your form, collect every submission, and send data where it needs to go — without building backend infrastructure.
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Point your form to your unique SplitForms endpoint. That's it.
Receive submissions
We instantly capture and organize every submission in your inbox.
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“Leads land in Slack the second someone submits, and a copy goes to Google Sheets for the sales team. I wired both up in under ten minutes.”
“I run a static Hugo site on a five-dollar VPS. splitforms gave it a real contact form without me standing up a single server.”
Questions
Physical Therapy Contact Form questions.
View all FAQsIs this form HIPAA-compliant?
The form collects scheduling information — contact details, body area, insurance carrier — not treatment records or diagnoses, which is the standard pattern for appointment-request forms. 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
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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