Doctors Appointment Form

Enable patients to request appointments with health info.

Doctors Appointment Form

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Doctors Appointment Form

First Name *

Last Name *

Phone Number *

Email Address *

Gender *

Date of Birth *

Address

Address Line 1 *

Address Line 2

City *

State *

Zip *

Country *

Have you previously attended our facility? * If Yes, state on which condition and when?

Appointment

Select which appointment type(s) you require * Appointment Date Notes

[section_break section_break-89 "Doctors Appointment Form"]


    
        <label> First Name *
            [text* first-name placeholder "Alex"] </label>
    
    
        <label> Last Name *
            [text* last-name placeholder "Piter"] </label>
    



    
        <label> Phone Number *
            [phone* phone-248] </label>
    
    
        <label> Email Address *
            [email* email-35 placeholder "[email protected]"] </label>
    



    
        <label> Gender *
            [select* select-376 first_as_label "Select" "Male" "Female"] </label>
    
    
        <label> Date of Birth *
            [date* date-940] </label>
    


<label> Address </label>
[address* address-736 format:international required_fields:line1|city|state|zip|country]

<label> Have you previously attended our facility? *
    [select* select-518 first_as_label "Select" "Yes" "No"] </label>

<label> If Yes, state on which condition and when?
    [textarea which-condition x3] </label>

[section_break section_break-405 "Appointment"]

<label> Select which appointment type(s) you require *
    [select appointment-type first_as_label "Select" "Allergy Testing" "Cardiology Appointment" "Chronic Pain Management" "COVID-19 Testing/Consultation" "Dental Checkup" "Diabetes Management" "Dietitian or Nutritionist Consultation" "ENT (Ear, Nose, Throat) Appointment" "Eye Checkup" "Follow-up Appointment" "Gastroenterology Appointment" "Gynecology Appointment" "Mental Health Counseling" "Neurology Appointment" "Oncology Consultation" "Orthopedic Consultation" "Pediatric Visit" "Physical Examination for Work or School" "Postnatal Checkup" "Prenatal Checkup" "Physiotherapy Session" "Routine Checkup" "Sexual Health Consultation" "Skin and Dermatology" "Sleep Disorder Consultation" "Smoking Cessation Counseling" "Surgery Consultation" "Urology Appointment" "Vaccination Appointment" "Weight Loss Consultation"] </label>

<label> Appointment Date
    [date_time* date_time-756 "m/d/Y"] </label>

<label> Notes
    [textarea notes x3] </label> 
    
[submit "Schedule"]

Input Fields Used in this Template

Explore the advanced functionalities that extend Contact Form 7, enhancing your form capabilities and optimizing user interactions

Section Break Field

Text Field

Phone Field

Email field

Dropdown select

Date picker

Address Field

Textarea field

Date Time Field

Submit button

Feature of this Template

Here is a quick overview of the features of this template, highlighting its key functions and how they can help you automate your process.

Personal Information Section: Fields for full name, age, gender, and contact details.
Appointment Type: Options to select whether it’s a general check-up, follow-up, emergency, or consultation for a specific issue.
Preferred Date and Time: A calendar picker to choose a suitable day and time slot for the visit.
Doctor Selection: A dropdown to select the preferred doctor or department (e.g., cardiology, pediatrics).
Symptoms and Concerns: A text box to describe current symptoms or health concerns.
Medical History: Space for mentioning previous diagnoses, allergies, medications, or ongoing treatments.
Insurance Information: Option to enter health insurance details if applicable.