Clinic Appointment Request Form template
Request a clinic callback with appointment preferences and no medical details. Copy the accessible markup, adjust the fields, and publish it with Core Forms.
What your visitor sees
Plain semantic HTML rendered through the same default form theme Core Forms applies on the front-end. Try it — this demo confirms inline and sends nothing.
Demo only. On your site, the same markup wires into the normal Core Forms action loop — email, Slack, Google Sheets, webhook, whatever you configure.
The HTML behind it
Copy this block, paste into Core Forms → Add New Form → Fields tab, save. Field names map to merge tags automatically in your action templates.
<p>
<label for="cf-field-NAME">Your name</label>
<input type="text" id="cf-field-NAME" name="NAME" autocomplete="name" required />
</p>
<p>
<label for="cf-field-EMAIL">Email address</label>
<input type="email" id="cf-field-EMAIL" name="EMAIL" autocomplete="email" required maxlength="254" />
</p>
<p>
<label for="cf-field-PHONE">Phone (optional)</label>
<input type="tel" id="cf-field-PHONE" name="PHONE" autocomplete="tel" />
</p>
<p>
<label for="cf-field-VISIT">Appointment category</label>
<select id="cf-field-VISIT" name="VISIT" required><option value="">Choose an option</option><option value="new-patient-appointment">New patient appointment</option><option value="follow-up-appointment">Follow-up appointment</option><option value="general-inquiry">General inquiry</option></select>
</p>
<p>
<label for="cf-field-PREFERRED_DATE">Preferred date</label>
<input type="date" id="cf-field-PREFERRED_DATE" name="PREFERRED_DATE" required />
</p>
<p>
<label for="cf-field-CONTACT_TIME">Best time to contact you</label>
<select id="cf-field-CONTACT_TIME" name="CONTACT_TIME" required><option value="">Choose an option</option><option value="morning">Morning</option><option value="afternoon">Afternoon</option><option value="evening">Evening</option></select>
</p>
<p>
<label for="cf-field-MESSAGE">Anything else we should know? (optional)</label>
<textarea id="cf-field-MESSAGE" name="MESSAGE" rows="4"></textarea>
</p>
<p>
<label><input type="checkbox" id="cf-field-CONTACT_CONSENT" name="CONTACT_CONSENT" required value="yes" /> You may contact me about this request.</label>
</p>
<p>
<button type="submit" id="cf-field-SUBMIT" name="SUBMIT">Request an appointment</button>
</p>
What this clinic appointment request form template is for
Use it for a clinic or practice that confirms appointments by phone or email.
This version asks only for information needed to complete that job. Do not collect symptoms, diagnoses or medical records on a website form. Take those through your clinical systems.
The markup uses explicit labels, useful autocomplete values, and fieldsets for grouped choices. You can edit every line instead of working around a locked template schema.
Every field, and why it's there
| Field | Type | Required | Why it's there |
|---|---|---|---|
| Your name | text | Yes | Identifies the person so the reply can use their name. |
| Email address | email | Yes | The reply and the automatic acknowledgement both go here. |
| Phone (optional) | tel | Optional | Optional, for people who would rather take a call. |
| Appointment category | select | Yes | The appointment category, for routing to the right team. |
| Preferred date | date | Yes | The preferred appointment day. |
| Best time to contact you | select | Yes | When the clinic should call back. |
| Anything else we should know? (optional) | textarea | Optional | Optional room for anything the fixed questions missed, capped at 2,000 characters. |
| You may contact me about this request. | checkbox | Yes | Permission to reply about this request only. It does not subscribe anyone to marketing email. |
From this HTML to a working form
- 1
Create the form from a template
In Core Forms, add a new form and choose the Clinic Appointment Request Form starting point, or paste the HTML below into code mode.
- 2
Remove what you will not use
Delete unnecessary fields, update the labels and choices, then set the success message to explain what happens next.
- 3
Test the whole path
Submit the form with realistic data. Verify validation, the saved submission, notification email, autoresponder, and any integration action.
Three upgrades worth considering
Show fields only when needed
Keep the first view short and reveal follow-up questions from an earlier answer.
Use conditional logic →Route the submitted data
Send the result to email, a CRM, a spreadsheet, or a signed webhook after validation.
Explore integrations →Check the funnel
Measure starts, successful submissions, and field drop-off after the form has real traffic.
Use form analytics →Clinic Appointment Request Form template questions
Is this clinic appointment request form template free to copy?
Yes. The HTML on this page is free to copy and adapt. Core Forms is required only if you want its WordPress submission handling, inbox, actions, analytics, and other plugin features.
Can I change or remove fields?
Yes. The form is plain HTML. Remove any field you cannot justify, rename fields before collecting data, and keep every label associated with its control.
Does the template save submissions in WordPress?
Core Forms can save successful submissions in its WordPress inbox. Storage is a per-form setting, so you can disable it for forms whose data should not be retained.
Can the form send a confirmation email?
Yes. Add an autoresponder action, map its recipient to the submitted email field, and state what the person should expect next.
How should I test it?
Use realistic valid data, missing required data, a malformed email address, keyboard-only navigation, and a narrow mobile viewport. Also verify every configured action and redirect.
The template is free. The plumbing is the product.
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