Doctor Appointment Form

Example image

A doctor appointment form is a document used to request, schedule, or confirm an appointment with a healthcare provider. This form can be used by patients or caregivers to provide necessary information to the medical office, ensuring that appointments are set up efficiently and that the healthcare provider is prepared for the visit.

Use template Clone into your account and use
Preview Check out the form

Doctor Appointment Form FAQs

You can collect the following information on a doctor appointment form.

  1. Header

    • Title of the form (e.g., "Doctor Appointment Form")
    • Medical practice name and logo

  2. Patient Information

    • Full name of the patient
    • Date of birth
    • Contact information (phone number, email address)
    • Address

  3. Appointment Details

    • Preferred date and time for the appointment
    • Alternative dates and times (if the first preference is not available)
    • Reason for the appointment (e.g., routine check-up, follow-up visit, specific health concern)

  4. Doctor/Provider Information

    • Name of the doctor or healthcare provider the appointment is with
    • Department or specialty (if applicable)

  5. Insurance Information

    • Insurance provider
    • Policy number
    • Group number (if applicable)

  6. Medical History

    • Brief medical history relevant to the appointment (e.g., existing conditions, current medications)

  7. Additional Information

    • Any specific questions or concerns to be addressed during the appointment

  8. Consent and Privacy

    • Consent for the collection and use of medical information
    • Privacy statement outlining how the information will be used and protected

  9. Signature

    • Signature of the patient or guardian (if the patient is a minor)
    • Date of signature

After you complete editing your new form and are satisfied with its look and feel, you can browse over to the "Share" section of the editor. Here you can copy the URL and share it on your website, or email it. You can also use the link to share on your social media. A QR code is also shown and you can copy this image and share it where users can easily scan the code with a mobile phone. You could also embed the form directly on your website or blog making it easier for people to access your form.

Yes, you can. After you use the template form to create a new form, you can edit various details including the messages shown to the user, colors, fonts and more. You can also apply a theme matching your brand colors. This will make your form more appealing to your users.