New patient registration form
Register new patients before their first visit with contact details, date of birth, insurance and reason for visit.
Dental appointment request form
Reception teams in dental practices spend a lot of phone time working out why a patient wants to come in and when they're free. This form asks exactly that: whether they're new to the practice, the reason for the visit, a preferred day and time of day, and how to reach them. Urgent problems stand out in the list, so you can call those patients back first.
Opens as an editable form in your dashboard. If you're not signed in yet, you'll sign in or create an account first.
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What's in this template
Every field can be renamed, reordered, made optional or removed in the form builder.
- Have you visited us before?Single choice · Required
- Reason for your visitDropdown · Required
- Preferred dateDate · Required
- Preferred time of dayDropdown · Required
- Anything we should know before your visit? (optional)Long answer · Optional
- Full nameShort answer · Required
- Phone numberPhone · Required
- EmailEmail · Required
- 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 reasons to match the treatments your practice offers, and keep "Something else" for anything that doesn't fit.
- Use a conditional field to show an extra question only when someone picks "Toothache or urgent problem", such as where it hurts.
- Add a short paragraph that tells patients what to do in an emergency outside your opening hours.
- Turn on the auto-responder so patients get an email saying their request arrived and that the practice will confirm a time.
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
Can patients book a fixed time with this form?
No. Patients send a request with a preferred day and time of day, and your team confirms the appointment. If you'd rather let patients pick from your real free slots, use Zotview's online booking system.
Why is there a consent checkbox?
Patients may mention health details, such as pain or feeling anxious about treatment. The checkbox records that they agree to the practice storing and using what they've shared to prepare for the appointment. Adjust the wording to match your own privacy notice.
Who is notified about new requests?
Each request is emailed to your account address and saved under Submissions in your dashboard. Add your reception's address as a further recipient in the form's settings.
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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.