Booking, classic form
Appointment request template (classic)
An appointment request that checks for emergencies first, then who it is for, urgency, visit type, clinician preference and availability.
17 questions, 16 required, as a classic form
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Every question
First, is this an emergency? (required)
Single choice: No, this can wait for an appointment, It is uncomfortable but it can wait, I am not sure, please ring me today
Who is the appointment for? (required)
Single choice: Me, My child, Someone I care for, and I am allowed to act for them, Someone else, and I will ask them to send this themselves
Name of the person being seen (required)
Full name
Their date of birth (required)
Date
Have they been seen here before? (required)
Single choice: Yes, regularly, Yes, but a long time ago, No, this would be the first time, I am not sure
What would you like to be seen about? (required)
Long answer
Does any of this apply right now? (required)
Multiple choice: Getting noticeably worse each day, Unable to do normal daily things because of it, Already been advised by somebody else to be seen, Recently in hospital or had surgery, Currently pregnant, None of these
How soon would you like to be seen? (required)
Single choice: Today or tomorrow if possible, Within the week, Within the month, It is routine, any time
How would you rather the appointment happened? (required)
Single choice: In person at the practice, By phone, By video call, In person, and I would like a home visit discussed
Is there someone in particular you would like to see? (required)
Single choice: No preference, whoever is free soonest, The person who usually sees me, Any female clinician, Any male clinician, A specific person, named in the notes
When could you come in? (required)
Multiple choice: Weekday, before nine, Weekday, during the day, Weekday, after five, Saturday morning, Any of these, I am flexible
Would you like to be told about cancellations? (required)
Single choice: Yes, text me about short notice slots, Yes, but only for this week, No thank you
Best phone number (required)
Short answer
If we cannot reach you, may we leave a message? (required)
Single choice: Yes, a voicemail with the details is fine, Yes, but only ask me to call back, with no details, No voicemail, please text me instead, No message at all, keep trying
Email address (required)
Short answer
Anything that would help us get the appointment right?
Multiple choice: An interpreter is needed, language in the notes, Step free access or a wheelchair space, The hearing loop, Extra time, because appointments are difficult, Somebody will attend with me, Nothing needed
Before you send this (required)
Multiple choice: I understand this is a request and not a confirmed appointment, I will give at least twenty four hours notice if I cannot come, I agree to my details being stored under the practice privacy notice
What you fill in
- [Your company]