Dental appointment request form
Patients request a check-up or treatment with their reason for visit, preferred day and time of day.
Medical history form
A short medical history before the appointment saves the first minutes of the consultation and helps the doctor spot what matters, such as blood thinners before a procedure or an allergy to a local anaesthetic. This template asks for the common points as a tick list and three short text questions, all optional, and keeps the personal part to name and contact details. Use it next to the new patient registration form, or on its own before a procedure.
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.
- Full nameShort answer · Required
- Date of birth (optional)Date · Optional
- Phone numberPhone · Optional
- EmailEmail · Optional
- Does any of the following apply to you? (optional)Multiple choice · Optional
- Medicines you take regularly (optional)Long answer · Optional
- Allergies (optional)Long answer · Optional
- Operations or hospital stays in the last few years (optional)Long answer · 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
- Edit the list of conditions to what your specialty really needs to know before a visit; a dental practice asks different questions from a dermatology clinic.
- Keep the health questions optional, so patients who would rather talk in person can still send the form.
- Send the form a few days before the appointment and say in the description who at the practice reads it.
- Adapt the consent text to your own privacy notice and link that notice in a paragraph above the checkbox.
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
How is this different from the new patient registration form?
The registration form records who the patient is, how to reach them and how visits are paid. This form is only about health: conditions, medicines, allergies and past operations. Many practices send both to new patients and only this one before a procedure.
Why are all health questions optional?
Health data is a special category of personal data under the GDPR and KVKK, so it's best to collect only what patients choose to share. Your doctor completes the history in the consultation.
Does the form ask for an insurance or ID number?
No. The template leaves out identity and insurance numbers on purpose. If your practice needs them, collect them at reception where you can check the documents.
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Zotview form builder
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.