BOOKINGS · CONTACT FORM TEMPLATE

Physical Therapy Appointment Request Form

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.

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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>

500

submissions / mo, free

fields, ready to ship

code outputs

60s

from copy to inbox

§ 01Why it mattersthe qualifying-fields argument

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.

✦ 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 · physical-therapy-contact-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 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.

Create your form

key=sk_live_••••••••

STEP 02EMBED

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'.

snippethtml

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

STEP 03RECEIVE

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.

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…25 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.

§ 06FAQ5 answered

Things people ask before they ship.

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

01Is 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.

02Do 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.

03Can 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.

04Should 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.

05How 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.

✻ ✻ ✻

Ship your physical therapy appointment request form in 60 seconds.

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

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