Acupuncture appointment request form template
This five-step acupuncture appointment form asks the reason for treatment, any past acupuncture, how often they want sessions and a preferred date, followed by the contact details. Clone it into your Growform account and add your treatments.
What the form asks, step by step
The form lets a new patient explain why they want acupuncture before choosing a date. A practitioner reads the request and knows what the first session is for.
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Step 1: “What are you seeking acupuncture for?”
Pain management, stress relief or overall wellness shapes the first treatment plan.
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Step 2: “Have you tried acupuncture before?”
First-time patients often need more explanation and a longer first appointment.
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Step 3: “How often do you typically get treatments?”
Weekly or monthly patients are likely candidates for a course of sessions.
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Step 4: “When would you like to see us?”
A date picker lets the patient suggest a day before anyone calls.
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Step 5: “How shall we contact you?”
Name, email and phone come last.
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After submitting
After submitting, patients see the standard thank-you screen, which a clinic would change to confirm when the appointment will be offered.
Who it’s for
Acupuncture clinics, integrative health practices and independent practitioners use this template to take appointment requests from their website. Every request arrives with the reason for treatment, the patient’s experience and a preferred date, so the clinic can offer a time in its first reply. It is not an acupuncture intake form, because it asks nothing about medical history. That intake belongs after the booking is confirmed.
Why this structure converts
- The first question asks what the patient wants help with, which is the reason they opened the page.
- Newcomers can say they have never had acupuncture, which removes the worry of being expected to know the process.
- A preferred date is chosen before the contact step, so the request already reads like a booking.
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Make it yours
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Send the intake form next
Keep health history off the website form. Send your full intake form by email once the appointment date is agreed.
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Rename the reasons
Replace the four reasons with the conditions you treat most, such as back pain, migraines or fertility support.
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Offer an introductory session
Use the thank-you screen to describe your first-visit offer, so new patients know what the initial appointment includes.
Send every lead where your team works
Frequently asked questions
What is the difference between this form and an acupuncture intake form?
This form requests an appointment and gives the practitioner context. An acupuncture intake form records medical history, medication and consent, and patients usually complete it before or at the first visit.
Can I use it as an acupuncture consultation form?
Yes. Add a step asking about symptoms or goals, and the practitioner can review the answers before a free consultation call.
Where do appointment requests go?
They go to your email by default, and they can also be sent to vcita, Keap or a Google Sheet through Growform’s integrations.
What happens next?
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Step 1: Clone this form template
Clone this template into your Growform account (create one first if you don’t already have one). -
Step 2: Edit your form
Get creative and adjust your form's theme options, questions or layout in the Growform form builder. -
Step 3: Share or embed your form
Share a link to your form, or embed it in your existing website. Receive new submissions by email or send them to 7,000+ apps via Zapier.
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