Dental appointment request form
Patients request a check-up or treatment with their reason for visit, preferred day and time of day.
Online consultation request form
Video and phone consultations work best when the practice knows what the call is about before it starts. This form asks for the format, a topic from a short list, a preferred day and time of day and an optional note, so you can plan the right length of call and the right person for it. A notice above the contact fields tells patients the form is not for emergencies.
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.
- How would you like to talk?Single choice · Required
- What is it about?Dropdown · Required
- Preferred dateDate · Required
- Preferred time of dayDropdown · Required
- What would you like to discuss? (optional)Long answer · Optional
- Full nameShort answer · Required
- Phone numberPhone · Optional
- EmailEmail · 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
- Change the topics to the kinds of remote consultation your practice really offers, and remove "Second opinion" if you don't give them.
- Say in the form description which video tool you use and that you'll send the link with the confirmation.
- Check which consultations your professional rules allow remotely in your country before you publish the form.
- Keep the emergency notice and write your local emergency number into it.
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
Does the form create a video call?
No. It collects the request. You confirm the time and send the link from the video tool you already use, for example in the confirmation email.
Why does the form say it's not for emergencies?
Requests arrive by email and wait until someone at the practice reads them. The notice makes sure nobody waits for a reply when they need help straight away.
Can patients describe their symptoms in detail?
There's one optional note field, and the description says a few words are enough. Detailed symptoms are better discussed in the consultation itself, which also keeps the health data you store to a minimum.
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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.