Dental appointment request form
Patients request a check-up or treatment with their reason for visit, preferred day and time of day.
Hair transplant and dental treatment pre-consultation form
Clinics that treat patients from abroad get most first enquiries by WhatsApp, often with a photo and the question "how much?". This form collects the first part in a form you can work with: the treatment, the country the patient travels from, when they'd like to come, the language they'd like a reply in and how to reach them. It asks patients not to send photos yet; your clinic requests them through a secure channel after the first contact. Your team can prepare a first consultation call instead of a long chat, and every request sits in one list.
Opens as an editable form in your dashboard. If you're not signed in yet, you'll sign in or create an account first.
This template is a starting point, not legal advice. Check the questions, the consent text and how long you keep the answers against the data protection rules that apply to your practice.
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What's in this template
Every field can be renamed, reordered, made optional or removed in the form builder.
- Which treatment are you interested in?Single choice · Required
- Which country would you travel from?Short answer · Required
- When would you like to travel?Dropdown · Required
- Anything else we should know? (optional)Long answer · Optional
- Which language should we reply in?Dropdown · Optional
- Full nameShort answer · Required
- Phone numberPhone · Optional
- EmailEmail · Optional
- How should we get back to you?Single choice · Optional
- ConsentCheckbox · Required
How to use this template
Open it in your dashboardSelect “Use this template”. If you don't have an account yet, sign up first; the form opens right after.
Make it yoursChange the questions, options, colours and the thank-you message in the form builder, then save.
Share it and get submissionsShare the form's link or link to it from your website. Each submission is emailed to you and saved in your dashboard.
Tips for this form
- Tell patients in the form description that a doctor prepares the first consultation and that a final plan needs an in-person examination.
- Don't promise prices or results in the form or its confirmation message; send a first assessment after the call.
- Edit the language list to the languages your coordinators really speak.
- Add a link to your privacy notice above the consent checkbox, and say how long you keep a request when no treatment follows.
Running a business like this? See how Zotview sets up the website, booking and forms for Clinics and practices.
Zotview for Clinics and practicesQuestions about this template
Why doesn't the form ask for photos?
Photos of a face, scalp or teeth are health data. The form collects only what you need to plan a first call, and a note asks patients to wait until your clinic requests photos through a secure channel after the first contact.
Can the clinic give a price from the form alone?
The form helps you prepare a first estimate, but the final treatment plan and price depend on an examination. Say so in your reply to avoid misunderstandings.
Where do the requests go?
Each request is emailed to your account address and saved in your dashboard. Add your patient coordinators as recipients in the form's settings, so only the team that prepares consultations sees them.
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Start with this form, change anything later
The template opens in the form builder, where you can edit every question and choose who receives the submissions.