Appointment Request Form Template

Patients use this form to request an appointment, share preferred dates and times, and choose how the practice can contact them.

Use this template free

When to use it

• Letting new patients request an initial visit
• Collecting appointment preferences from returning patients
• Offering appointment requests outside office hours
• Gathering alternate dates when preferred times are unavailable

What it asks

1. What is your name?
2. What is your email address?
3. What is your phone number?
4. Are you a new or returning patient?
5. What is your preferred appointment date?
6. What is your preferred appointment time?
7. What is an alternate appointment date?
8. What is an alternate appointment time?
9. What is the reason for your appointment?
10. How would you prefer us to contact you?

Why it should be encrypted

Contact details and the reason for an appointment can reveal private health information. Only staff who handle scheduling should be able to read these answers.

Tips

• Ask patients to keep the appointment reason brief and avoid sharing urgent or detailed medical information.
• Add your office hours and expected response time so patients know when to expect a reply.
• Include a separate instruction for urgent needs, such as calling your practice or local emergency services.

More Healthcare templates

• Authorization to Release Medical Records
• Chiropractic Intake Form
• Current Medications Form
• Dermatology Intake Form
• Insurance Information Update
• Medical History Form
• New Patient Intake Form
• Patient Referral Form

All form templates