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Healthcare7 fields

Medical Appointment Request

Let patients request appointments online.

Spam protectionEmail notificationsAI sales agentSubmission dashboardNo backend needed

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Exactly what visitors will see on your site

Medical Appointment Request

What you'll collect

Every field in this template, ready to use out of the box.

Patient Name

text · required

Email

email · required

Phone

tel · required

Preferred Date

date · required

Preferred Time

select · required

Reason for Visit

select · required

Additional Notes

textarea · optional

Copy the Code

Choose HTML for static sites or React for component-based apps. Replace YOUR_FORM_ID with your Flowqen endpoint ID.

<form
  action="https://flowqen.com/api/f/YOUR_FORM_ID"
  method="POST"
  class="max-w-xl mx-auto rounded-[32px] border-2 border-[#231b17] bg-[#fffdf9] px-6 py-7 shadow-none sm:px-8"
>
  <h2 class="text-2xl font-semibold tracking-tight text-[#231b17] mb-6">Medical Appointment Request</h2>


  <div class="space-y-4">
    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Patient Name</label>
      <input type="text" name="patientName" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" placeholder="John Doe" required />
    </div>


    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Email</label>
      <input type="email" name="email" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" placeholder="patient@email.com" required />
    </div>


    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Phone</label>
      <input type="tel" name="phone" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" placeholder="(555) 123-4567" required />
    </div>


    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Preferred Date</label>
      <input type="date" name="preferredDate" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" required />
    </div>


    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Preferred Time</label>
      <select name="preferredTime" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" required>
        <option value="">Select...</option>
        <option value="Morning (9-12)">Morning (9-12)</option>
        <option value="Afternoon (12-3)">Afternoon (12-3)</option>
        <option value="Evening (3-6)">Evening (3-6)</option>
      </select>
    </div>


    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Reason for Visit</label>
      <select name="visitReason" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8" required>
        <option value="">Select...</option>
        <option value="Annual Checkup">Annual Checkup</option>
        <option value="Follow-up">Follow-up</option>
        <option value="New Symptoms">New Symptoms</option>
        <option value="Referral">Referral</option>
        <option value="Other">Other</option>
      </select>
    </div>


    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#4f4138]">Additional Notes</label>
      <textarea name="notes" rows="4" class="w-full rounded-[18px] border border-[#d9cdc3] bg-white px-4 py-3 text-sm text-[#231b17] outline-none transition focus:border-[#231b17] focus:ring-4 focus:ring-[#231b17]/8 resize-none" placeholder="Any details about your visit..." required></textarea>
    </div>
  </div>


  <!-- Honeypot (spam protection) -->
  <div style="display:none">
    <input type="text" name="_gotcha" style="display:none" />
  </div>


  <button type="submit" class="mt-6 w-full rounded-[18px] bg-[#231b17] py-3 text-sm font-semibold text-white transition hover:bg-[#3a2f29]">
    Submit
  </button>
</form>

What is a Medical Appointment Request?

An online appointment request form for clinics and hospitals. Patients select preferred date, time, and reason for visit.

Frequently Asked Questions

Common questions about healthcare form templates.

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Collect feedback from patients after their visit.

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Start with this Medical Appointment Request

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