Healthcare
Clinic Appointment Request
Request a clinic visit with one question at a time.
Why use this template
A virtual visit fails when the time zone is missing. This request asks what kind of virtual visit they want, which time zone to use, and whether they will join from a phone, tablet, or computer. Then it collects a preferred date and how to confirm. Customize the visit types for your clinic and publish the form on the telehealth page of your site.
Part of Formgrid’s healthcare form templates workflow for organised enquiries and lead capture.
- Visit type, time zone, and device before the date
- One question at a time on a full screen layout
- Contact method for the confirmation
- Scheduling only, with a confirmation step
What this template collects
- Virtual visit type
- Time zone
- Phone, tablet, or computer
- Preferred date and time of day
- Name, email, and phone
- Preferred contact method
Who this template is for
Clinics offering virtual visits that need a scheduling request before they send a link.
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
Why ask for a device?
The clinic can see whether the person expects to join from a phone, tablet, or computer before sending instructions.
Can I change the time zone list?
Yes. Edit the choices to match the regions you serve.
Does this start the video visit?
No. It collects a scheduling request. Your team confirms the time and sends the visit link.