Use This Template

Appointment Request

Enable new and established patients to request appointments online with our free appointment request form template.

Simply customize the template to reflect your organization’s branding, and add or change any fields to work with your appointment scheduling system. Configure the workflow approval emails to notify the appropriate systems or staff members whenever a request is submitted or modified. Then embed it on your website to begin having patients request appointments online!

Please note that our Enterprise plans can be made HIPAA compliant.

With this powerful appointment confirmation workflow:

  • Patients submit appointment requests with multiple possible appointment times.
  • Patients receive confirmation of their requests via email and can easily modify or cancel pending requests.
  • Staff review submitted requests sent via email and confirm appointments, providing a reason if the requested physician or date/times cannot be accommodated.
  • Patients receive appointment confirmations via email and can easily reschedule or cancel their appointments up to the reschedule deadline appropriate for your office.
  • Staff receive reschedule and cancellation emails prompting them to reconfirm or remove appointments from internal systems/schedules.

Appointment Request

Use our free appointment request form template to enable patients to request appointments online.



  • Patient
  • Staff


  • Incomplete
  • Pending
  • Confirmed
  • Cancelled