FormClinics / Diagnostic Centres8 questions · ~2 min

Clinic Appointment Request form template

This free Clinic Appointment Request form template helps you collect appointment requests for the clinic to confirm. It has 8 ready-made questions, takes about 2 minutes to answer, and is anonymous by default. Customise every question, then share it by link, QR code or website embed.

Use this template — free All templates

Questions in this template

Patient’s full name *
Short text
Phone number *
Phone number
Email (optional)
Email address
Type of appointment *
Single choice
General consultation · Specialist consultation · Diagnostic test · Health check-up · Follow-up visit
Have you visited us before?
Single choice
Yes, I’m an existing patient · No, this is my first visit
Preferred date *
Date
Preferred time
Single choice
Morning · Afternoon · Evening
Anything we should know to book the right appointment?
Long text

* required. Every question is editable.

Recommended settings

Visibility: Unlisted — only people with the link
Responses: Anonymous — not linked to accounts
Results: Only you and your workspace see results
One response per: No limit (people can submit for others)
Consent notice: Included — edit it to match your policy

Best for: Preferred slots, minimal personal data, request acknowledgement.

Industries: Healthcare.

Tip: Keep this form to booking details. Don’t ask for medical history here.

Best practice for lead generation

Ask only for contact details you will actually use.
Keep the consent notice visible and specific.
Export to CSV or connect a webhook to send leads to your CRM.

Clinic Appointment Request: frequently asked questions

What questions should a Clinic Appointment Request form include?

A good Clinic Appointment Request form is short and focused. This template asks: Patient’s full name · Phone number · Email (optional) · Type of appointment — plus 4 more. Remove anything you won’t act on.

Is the Clinic Appointment Request form anonymous?

Yes. Responses are anonymous by default and aren’t linked to anyone’s account, although the form asks for contact details so you can reply.

How long does the Clinic Appointment Request form take to complete?

About 2 minutes — 8 questions. Shorter forms get more responses.

Can I customise the Clinic Appointment Request form template?

Yes. Every question, option and setting is editable before you publish, and you can add skip logic, pages, a cover image and translations into 20 more languages, from Chinese, Hindi and Spanish to Arabic, Bengali and Hausa.