Medical Referral Form — shared by the community
Priya N. shared this 13-question build with 3 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare, legal & specialized form for teams with a niche process that generic forms don't cover: 13 questions, 2 pages, 3 conditional rules.
- Shared by
- Priya N. · Operations lead
- Questions
- 13
- Replies
- 19
- Copies taken
- 616
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Live preview and test console
This is the real form. Answer it to test the 2 conditional rules — nothing is sent or stored.
Page 1 of 2 — Patient
Every question on this page is currently visible.
Works for you? Take Priya N.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Medical Referral Form is built for teams with a niche process that generic forms don't cover who need to capture reproducible detail on first contact.
- Teams with a niche process that generic forms don't cover working in healthcare, legal & specialized.
- Teams who need to capture reproducible detail on first contact without writing code or paying for a custom build.
- Anyone replacing requests that need three replies before work can start with one structured record per enquiry.
- Respondents are the specific group this workflow serves — the form asks them 13 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of requests that need three replies before work can start and turns each submission into a record your team can act on immediately.
- 10 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It accepts a document or photo upload as evidence.
- It records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Medical Referral Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Check the upload limits on the file question so respondents can attach what you actually need.
- 5Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 6Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features advanced show logic: if “Urgency” is Urgent, the form dynamically exposes “Urgent referrals”. Otherwise that question never appears.
- Features conditional validation: if “Urgency” is Urgent, “Phone” becomes mandatory before the form can be sent.
- Features advanced show logic: if “Is the patient aware of this referral?” is No, the form dynamically exposes “Please discuss with the patient first”. Otherwise that question never appears.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — Patient
- Patient namerequired
- Date of birthrequired
- Phonerequired
- Referring clinician and practicerequired
- Referred to (specialty or clinic)required
Page 2 — Clinical
- Reason for referralrequired
- Relevant history and medicationsrequired
- Urgencyrequired
- Urgent referrals
- Investigations attached
- Is the patient aware of this referral?required
- Please discuss with the patient first
- Referrer signaturerequired
Conditional logic in this build
- When “Urgency” is Urgent, show “Urgent referrals”.
- When “Urgency” is Urgent, require “Phone”.
- When “Is the patient aware of this referral?” is No, show “Please discuss with the patient first”.
Questions about this shared form
Is this suitable for urgent or emergency referrals?
It handles urgent referrals with a direct-contact route, but emergencies need a phone call. Say so plainly on the cover of your copy.
Who fills this in?
The referring clinician. Patient demographics can be pre-filled, but the clinical content and signature come from the referrer.
How is it different from an appointment request?
An appointment request comes from a patient who wants to be seen. A referral comes from a clinician and carries clinical reasoning for triage.
How should submissions be stored?
Restrict inbox access to the referral team and follow your organisation's retention rules — these submissions contain clinical information.
Is the Medical Referral Form template free to use?
Yes. You can preview and test Medical Referral Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Medical Referral Form template ask for?
It asks 13 questions across 2 pages, 10 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Medical Referral Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare, legal & specialized form work?
3 conditional rules ship with the template: Features advanced show logic: if “Urgency” is Urgent, the form dynamically exposes “Urgent referrals”. Otherwise that question never appears. Features conditional validation: if “Urgency” is Urgent, “Phone” becomes mandatory before the form can be sent. Features advanced show logic: if “Is the patient aware of this referral?” is No, the form dynamically exposes “Please discuss with the patient first”. Otherwise that question never appears. All rules are editable in the Logic tab.
Where do responses to the Medical Referral Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Medical Referral Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Can respondents upload files?
Yes. This template includes a file upload question, so respondents can attach documents or photos with their answers. You can adjust the accepted file types and size limits on that question.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
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