Clinic Contact Form
A clinic contact form has to do one thing before it collects anything: make absolutely clear that it is not for medical emergencies, and say where to go instead.
For clinics, practices and healthcare providers.
The safety notice is the most important text on the page
Somebody will eventually type chest pain into a contact form at 11pm. That is not a hypothetical - it happens to every clinic that publishes one, and what determines the outcome is whether the page told them, prominently, to call for help instead.
So the emergency notice is at the top here, before the first field, and repeated at the point of submission. Everything else on the form - routing by enquiry type, patient status, a reference for existing patients - is ordinary good practice by comparison.
Better than publishing your email address
A mailto link gets you spam and messages with no context. A form gets you the same enquiry with the details you need, in a list you can search, and no address for a scraper to harvest.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Nothing to consent to
No analytics, no third-party scripts, no cookie banner - so the page that asks people to trust you with a message isn't also asking them to accept trackers.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Your name
- Email address
- Phone number
- Are you a patient here?
- Date of birth
- What's this about?
- Your message
- How would you like us to reply?
- I understand this form is not for urgent medical problems
More Healthcare forms
Questions
Should medical questions be answered by email at all?
Generally no. Use the form to route the enquiry and reply through your clinical channel. Say on the form that clinical advice isn't given by email so nobody waits for an answer that isn't coming.
Can we route enquiries to different departments?
Ask the enquiry type and notify a triage inbox - the answer appears in the email subject, so it can be forwarded once, correctly.
Will I get spam?
Far less than a published email address. Every form carries a hidden trap field that automated submitters fill in and humans never see, and those submissions are silently discarded.
Can I send messages to a shared inbox?
Yes. Notifications go to a list of addresses you choose, so a team alias works as well as one person.
Can I add this to my website?
Link to it from anywhere - a button, a nav item, a footer. It's a normal page with its own URL, so no embedding or code is required.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your clinic contact form today
Start from this template and change anything you like. Free to begin.