Healthcare
Clinic Appointment Request
Request a clinic visit with one question at a time.
Why use this template
Imaging schedules fall apart when the only request is a voicemail. This form asks which desk the appointment belongs to, what kind of slot they need, and when they can arrive. It does not ask for clinical detail. Customize the desk names for your center, then let the scheduling team confirm from a single pipeline.
Part of Formgrid’s healthcare form templates workflow for organised enquiries and lead capture.
- Separate questions for the desk and the slot type
- Date, time of day, and a contact method
- Optional note limited to scheduling
- A full screen preview you can click through before customizing
What this template collects
- Appointment desk
- Slot type
- Preferred date and time of day
- Optional scheduling note
- Name, email, and phone
- Preferred contact method
Who this template is for
Imaging centers that want a scheduling request before they confirm a slot.
Formgrid features included
- One question on each screen, with a welcome page and a thank you page
- Email notification when a request arrives
- Lead pipeline with New, Contacted, and Converted
- Spam protection on every submission
- Shareable link, or embed the form on your website
- Free to customize. No code required
How it works
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1
Open the live preview and walk through the questions.
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2
Choose Customize Free and edit the wording, colors, and fields.
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3
Publish a link or embed the form on your clinic website.
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4
Each submission lands in Formgrid so your team can follow up.
Live preview
Click through the form, then customize the questions for your own copy.
Frequently asked questions
Which imaging desks are included?
The starter choices are X-ray, ultrasound, MRI, CT, and not sure. Replace them with your own desks.
Does the form ask why the imaging was ordered?
No. It asks for a scheduling slot and contact details only.
Can the center get an email for each request?
Yes. Turn on the email notification and review the request in Formgrid.