Dental Appointment Request Form
A dental appointment request form should sort a broken tooth from a six-month check in the first two questions. One needs a slot today; the other can wait for the recall list.
For dental practices, orthodontists and hygienists.
Pain level is a scheduling field
Reception spends its day making judgement calls about urgency from half-descriptions given over the phone. A pain scale and a short list of symptoms turns that into a sortable answer - and a patient who ticks "kept me awake" gets found in the list rather than buried in it.
The other question that changes everything is whether they're a new patient. New patients need longer, often need radiographs, and need a medical history form before they arrive - so it's worth knowing before the appointment is offered.
Fewer no-shows, fewer surprises
No-shows and "I thought I booked the other thing" both come from the same place: a booking nobody wrote down properly. When the patient types it themselves, there's a record, in their words, of exactly what was asked for.
Medical history before the chair, not in it
Medical history, medication and anxiety level asked at reception get rushed and under-reported. Sent with the appointment confirmation, they arrive complete, read properly, and give you the ten minutes back.
It also flags the appointments that need different planning - a sedation conversation, a longer slot, a change of technique - before the day rather than at the door.
Confirm in writing, immediately
The moment they submit, they see a confirmation and you get an email. No wondering whether it arrived - which is the thing that makes people phone you anyway.
Edit it like a document, publish like a link
Add questions, remove questions, change the order and the wording, set your accent colour. When you save, the form is live at its own address - share it by link, QR code or a button on your site, and read the answers in your dashboard.
What this template asks
- Your name
- Email address
- Phone number
- Date of birth
- Are you an existing patient?
- What do you need?
- How much pain are you in?
- Any of these?
- Anything you'd like to tell us?
- When are you usually free?
- Earliest date that suits you
- Any preference?
- Add me to the cancellation list for an earlier slot
More Dental forms
Questions
Can we take emergency requests this way?
Only alongside a phone number for genuine emergencies, and say so on the form. A form is right for triage during the day and wrong for severe pain at 10pm.
Can we send the medical history form afterwards?
Yes - most practices reply with the intake form link. Because the appointment request already tells you whether they're new, the right form goes out automatically.
Does this book the slot automatically?
No - it collects a request, and you confirm it. That's deliberate: real diaries have exceptions, and a form that promises a slot you can't honour costs more than one that asks.
Can I limit the options people can pick?
Yes. The service and time-of-day lists are yours to edit, so people can only choose from what you actually offer. You can also close the form when you're full.
Will I know straight away?
Yes, if you want to be. Turn on live notifications and every request is emailed to you the moment it arrives; otherwise collect them and read them in your dashboard.
Can this hold patient medical information?
Responses are stored in your account, never shared, and served over encrypted connections - but you are the data controller. Ask only what you need clinically, tell patients what you keep, and check your local rules (HIPAA, UK GDPR and similar) before using a web form for health data.
Publish your dental appointment request form today
Start from this template and change anything you like. Free to begin.