Patient Referral Form — shared by the community
Rachel O. shared this 19-question build with 3 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 19 questions, 2 pages, 3 conditional rules.
- Shared by
- Rachel O. · Events coordinator
- Questions
- 19
- Replies
- 23
- Copies taken
- 524
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Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 2 — Referrer and patient
This template runs as a straight sequence — no branching rules.
Works for you? Take Rachel O.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Patient Referral Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 19 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 chasing missing details over email and turns each submission into a record your team can act on immediately.
- 15 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It collects a verified email address so replies and confirmations land.
- It captures a phone number for urgent follow-up.
- It accepts a document or photo upload as evidence.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- 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.
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 Patient 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 conditional validation: if “Urgency” is Urgent, “Why this is urgent” becomes mandatory before the form can be sent.
- Features conditional validation: if “Have any investigations been done?” is Yes, “Attach results or reports” becomes mandatory before the form can be sent.
- Features conditional validation: if “Does the patient need an interpreter?” is Yes, “Which language?” becomes mandatory before the form can be sent.
- 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 — Referrer and patient
- Referring clinician namerequired
- Practice or servicerequired
- Referrer email addressrequired
- Direct number for queriesrequired
- Patient full namerequired
- Patient date of birthrequired
- Patient contact numberrequired
- Does the patient need an interpreter?required
- Which language?
Page 2 — Clinical detail
- Reason for referral in one linerequired
- Relevant historyrequired
- Current medication
- What has been tried, and what happenedrequired
- Have any investigations been done?required
- Attach results or reports
- What are you asking for?required
- Urgencyrequired
- Why this is urgent
- Patient awarenessrequired
Conditional logic in this build
- When “Urgency” is Urgent, require “Why this is urgent”.
- When “Have any investigations been done?” is Yes, require “Attach results or reports”.
- When “Does the patient need an interpreter?” is Yes, require “Which language?”.
Questions about this shared form
Can patients refer themselves with this?
It is written for clinician-to-clinician referrals. For self-referral, use the Clinic Appointment Request, which asks the same clinical basics in patient-friendly wording.
Do we need consent to receive a referral?
The awareness checkbox records that the patient knows. Where records are being transferred rather than summarised, pair it with the Records Release Form.
How do we handle urgent referrals safely?
State plainly in the intro that the form is checked during working hours and give a telephone route for anything that cannot wait for triage.
Can we adapt the fields to our service?
Yes, and receiving services should: adding two or three specialty-specific questions is what stops the generic referral arriving without the detail you always need.
Is the Patient Referral Form template free to use?
Yes. You can preview and test Patient 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 Patient Referral Form template ask for?
It asks 19 questions across 2 pages, 15 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 Patient 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 & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “Urgency” is Urgent, “Why this is urgent” becomes mandatory before the form can be sent. Features conditional validation: if “Have any investigations been done?” is Yes, “Attach results or reports” becomes mandatory before the form can be sent. Features conditional validation: if “Does the patient need an interpreter?” is Yes, “Which language?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Patient 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 Patient 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.
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