Fill Your Schedule Without Phone Tag
Appointment Request Form
Let patients request appointments 24/7 while your staff focuses on care—automatic routing matches urgency to availability.
About This Template
Your front desk drowns in phone calls. Staff spend 6-8 hours daily answering appointment requests, putting callers on hold, and playing phone tag with patients who can't answer during business hours. Meanwhile, online patients expect 24/7 booking—and 67% will switch providers for better scheduling convenience. Every missed call is potentially a lost patient.
This template lets patients request appointments anytime from any device. They specify appointment type, urgency level, preferred dates/times, and reason for visit. Conditional logic shows relevant fields (new patient vs. established, sick visit vs. routine). Staff receive organized requests with all information needed to schedule—no back-and-forth calls.
Reduce appointment-related calls by 60%. Staff process requests in batches—3 minutes per request vs. 8 minutes per phone call. Patients get confirmation within hours, not days. Urgent requests surface automatically for same-day scheduling. Fill cancellation slots faster by matching patient preferences to open times.
Key Features
- Patient identification
- Appointment type selection
- Date/time preferences
- Reason for visit
Use Cases
Multi-Provider Primary Care
Your primary care practice has 6 providers with different schedules and specialties. Patients call requesting specific doctors, but front desk can't always check availability while on the phone. Callbacks take hours, and patients often can't answer during business hours.
Pain point: Phone tag wastes staff time—average 3 call attempts per appointment. Patients frustrated when preferred provider is unavailable but they've already waited on hold.
Urgent Care Triage
Your urgent care sees walk-ins and scheduled patients. Some patients call with symptoms that could be handled via telehealth or need same-day appointments, while others can wait. Without triage information upfront, staff can't prioritize scheduling.
Pain point: No way to assess urgency before patient arrives. Truly urgent cases wait while routine requests tie up staff. Same-day slots go to whoever calls first, not who needs them most.
Specialist Referral Coordination
Your specialist practice receives referrals requiring specific appointment types (initial consultation, follow-up, procedure). Patients call without referral information, requiring staff to track down records before scheduling.
Pain point: Staff spend 15+ minutes per call gathering referral information. Patients scheduled for wrong appointment type must be rescheduled, wasting provider time.
After-Hours Request Capture
Your practice closes at 5pm, but patients want to schedule after work hours. Voicemails pile up overnight—staff arrive to 30+ messages requiring callbacks. Many patients have already scheduled elsewhere by the time you call back.
Pain point: 40% of scheduling attempts happen after business hours. Voicemail callbacks have 50% answer rate. Patients who can't be reached often book with competitors.
Form Fields (16)
Patient Information
First Name
Last Name
Date of Birth
Phone Number
(555) 123-4567Email Address
your@email.comAre you a new patient?
Appointment Details
Appointment Type
Select appointment type...Preferred Provider
Select preferred provider...Preferred Date (1st choice)
Preferred Date (2nd choice)
Preferred Time
Select preferred time...Urgency Level
Select urgency level...Reason for Visit
Briefly describe why you need this appointment...Current Symptoms (if applicable)
Describe any symptoms you are experiencing...Customization Tips
Add Provider-Specific Availability
Use conditional logic to show different available time slots based on selected provider. Each provider can have their own schedule displayed.
Enable Insurance Pre-Verification
Add insurance fields and integrate with verification API to check coverage before confirming appointment. Flag patients with coverage issues.
Add Symptom Checker for Urgency
Add conditional symptom questions that help determine true urgency. Chest pain or difficulty breathing auto-flags as urgent.
Connect to Calendar System
Integrate with practice management system to show real-time availability and auto-book confirmed appointments.
Add New Patient Pre-Registration
When isNewPatient is true, show additional fields to collect demographics and insurance before appointment.
Suggested Workflows
Acknowledge Request Immediately
Trigger: On form submissionWhen appointment request is submitted, immediately email patient: "We received your request for a [appointment type] appointment. Our team will confirm your appointment within 4 business hours." Reduces "did you get my request?" calls.
Route Urgent Requests Immediately
Trigger: On submission where urgency = UrgentWhen urgency = "Urgent - Need to be seen today", immediately notify triage nurse via SMS and email. Request appears at top of scheduling queue with red flag.
Batch Notify Scheduling Staff
Trigger: Scheduled - every 30 minutes 8am-5pmEvery 30 minutes during business hours, send scheduling staff a summary of pending requests sorted by urgency and preferred date. Staff process in batches efficiently.
Send Confirmed Appointment Details
Trigger: When appointment status changes to confirmedAfter staff confirms appointment, automatically email patient with date, time, provider, location, and preparation instructions specific to appointment type.
Developer Notes
Schema Highlights
Urgency field enables priority sorting—index on {urgency: 1, createdAt: 1} for queue management
Preferred dates stored as separate fields allow flexible matching against provider availability
isNewPatient boolean triggers different workflows and field visibility
Integration Hints
Practice management system API (Athena, eClinicalWorks) for real-time availability checks
Calendar API integration to auto-populate available slots based on provider schedules
Twilio/SMS integration for urgent request notifications to clinical staff
MongoDB Considerations
Index on {urgency: 1, status: 1, createdAt: 1} for scheduling queue queries
Index on {preferredDate1: 1, appointmentType: 1} for availability matching
TTL index on completed requests (>30 days) to archive old scheduling data
Consider compound index on {provider: 1, preferredDate1: 1} for provider-specific scheduling
Tags
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Complexity
Form Type
Est. Completion
~4 min
Total Fields
16
Category
Healthcare & Wellness
Export & View
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