Dental consultation request form template
This four-step dental consultation request form asks the treatment of interest, the patient’s smile concerns and a preferred date and time, followed by the contact details. You can clone it into your Growform account and list your own treatments.
What the form asks, step by step
The form is built for cosmetic and restorative work, where a patient usually knows the result they want before they know the treatment. It moves from treatment to concerns to timing.
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Step 1: “What type of dental procedure are you interested in?”
Braces, veneers and implants each go on a different clinician’s calendar.
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Step 2: “What are your main concerns about your smile?”
Patients can select staining, missing teeth, alignment and chips in one answer.
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Step 3: “When is best for an initial consultation?”
A date and a time of day let the practice propose a real slot.
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Step 4: “How shall we get in touch?”
Name, email and phone come last.
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After submitting
After the “Request more info” button, patients see a brief thank-you that you can change to name the person who will call.
Who it’s for
General and cosmetic dental practices use this template on treatment pages for braces, veneers and implants, where visitors compare clinics before committing to a visit. Each submission tells the treatment coordinator what the patient is interested in, what bothers them about their smile and when they could come in. That is enough to prepare a cosmetic dentistry consultation call that starts with the patient’s own words. Unlike a dental appointment form for registered patients, it asks nothing about medical history. Implant-focused practices can use the dental implant consultation form instead.
Why this structure converts
- “Other / not sure” on the first step lets a patient continue without knowing the clinical name for what they want.
- The concerns step is multi-select, so a patient with several issues can say so on one screen.
- The date picker on step three turns an inquiry into a proposed appointment before anyone calls.
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Make it yours
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Check the option wording
The concerns list includes a receding gums option that is misspelled in the template. Correct it, and rename any option to match the language on your treatment pages.
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Show your own results
Answer buttons can show images. Photos of your own veneer and orthodontic cases on the first step show the quality of your work while the patient chooses.
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Mention finance options
If you offer payment plans, add a yes-or-no question about finance before the contact step so the coordinator brings the right figures to the call.
Send every lead where your team works
Frequently asked questions
What should a dental consultation form ask?
It should ask which treatment the patient is considering, what they want to change about their smile and when they could attend. This template asks those three things and then the name, email and phone number.
Is this a dental appointment form for existing patients?
It is designed for new patients who are exploring treatment. Existing patients booking a checkup are better served by your practice management system.
Does it collect medical history?
No. Medical history and consent forms are completed after the consultation is booked. Keeping them off the website makes the form quicker to finish and limits the health data you hold before a visit.
Which tools can receive the requests?
Requests arrive by email and can also be sent to DenGro, HubSpot, vcita or a Google Sheet, so the front desk works from one list.
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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