Telehealth Appointment Request — shared by the community
Marta K. shared this 10-question build with 2 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: 10 questions, 1 page, 2 conditional rules.
- Shared by
- Marta K. · Practice manager
- Questions
- 10
- Replies
- 5
- Copies taken
- 802
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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.
2 questions are hidden by conditional logic right now — change an answer above to reveal them.
Works for you? Take Marta K.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Telehealth Appointment Request 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 10 questions across 1 screen.
- 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.
- 5 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 pins the request to a specific date.
- It allows multiple selections without free text.
- Conditional logic hides 2 questions until they are relevant — shorter forms convert better than long ones.
- 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 Telehealth Appointment Request 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.
- 4Publish 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.
- 5Watch 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 — 2 conditional rules ship with it.
- Features advanced show logic: if “Are you a new or returning patient?” is New patient, the form dynamically exposes “Date of birth”. Otherwise that question never appears.
- Features advanced show logic: if “What symptoms are you experiencing?” includes Chest pain, Difficulty breathing, or Severe allergic reaction, the form dynamically exposes “Please call emergency services or go to your nearest emergency department”. Otherwise that question never appears.
- All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Request a virtual visit
- Are you a new or returning patient?required
- Full namerequired
- Email addressrequired
- Phone number
- Date of birth
- What symptoms are you experiencing?required
- Briefly describe what's going on
- Do you have a working camera and stable internet for a video call?required
- Preferred appointment date
- Preferred time of day
Conditional logic in this build
- When “Are you a new or returning patient?” is New patient, show “Date of birth”.
- When “What symptoms are you experiencing?” includes Chest pain, Difficulty breathing, or Severe allergic reaction, show “Please call emergency services or go to your nearest emergency department”.
Questions about this shared form
Does this form perform medical triage?
No — the urgent-symptom message is a safety prompt directing patients to appropriate care, not a diagnosis or clinical assessment.
Can I use this for phone-only telehealth?
Yes — the tech-check question already accounts for phone-only visits as an option.
Why keep this a card/one-question layout?
Symptom-driven bookings are usually done quickly, often on a phone, so a shorter conversational flow reduces drop-off compared to a long single page.
Should returning patients still describe their symptoms?
Yes — the symptom checklist and description field stay the same for both patient types; only the extra identity fields are skipped for returning patients.
Is the Telehealth Appointment Request template free to use?
Yes. You can preview and test Telehealth Appointment Request 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 Telehealth Appointment Request template ask for?
It asks 10 questions across 1 page, 5 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 Telehealth Appointment Request form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the card and classic 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?
2 conditional rules ship with the template: Features advanced show logic: if “Are you a new or returning patient?” is New patient, the form dynamically exposes “Date of birth”. Otherwise that question never appears. Features advanced show logic: if “What symptoms are you experiencing?” includes Chest pain, Difficulty breathing, or Severe allergic reaction, the form dynamically exposes “Please call emergency services or go to your nearest emergency department”. Otherwise that question never appears. All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.
Where do responses to the Telehealth Appointment Request 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 Telehealth Appointment Request 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.
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