Physical therapy appointment request form template
This five-step physical therapy appointment form asks the kind of therapy needed, session frequency, any therapist gender preference and the time of day available, followed by the contact details. Clone it into your Growform account and list your specialties.
What the form asks, step by step
The questions give a clinic what it needs to assign the right therapist and schedule. Clinical details come later, once the patient is booked.
-
Step 1: “What kind of physical therapy are you interested in?”
Sports rehab, post-surgery, pediatric or general physiotherapy points to the right clinician.
-
Step 2: “How often do you expect to need therapy sessions?”
Weekly or several sessions a week tells you how much capacity to hold.
-
Step 3: “Do you have a preferred physical therapist gender?”
Some patients prefer a male or female therapist, and asking up front avoids awkwardness.
-
Step 4: “What time of day are you available for sessions?”
Morning, afternoon or evening availability matches the patient to open slots.
-
Step 5: “How shall we contact you?”
Name, email and phone come last.
-
After submitting
A standard thank-you appears after submission, and clinics usually replace it with directions and what to wear to the first session.
Who it’s for
Physical therapy clinics, sports rehabilitation centers and independent physiotherapists use this template to accept new patients online. Each request says what kind of therapy is needed, how many sessions a week the patient expects and when they are free, which is enough to assign a therapist and propose a start date. The physical therapy intake form, with injury history and referral details, can follow once the first session is booked.
Why this structure converts
- Patients choose their type of therapy from four familiar options rather than describing a diagnosis.
- The therapist preference question respects a sensitive choice and saves a reassignment later.
- Availability is asked as a time of day, which is easy to answer for people fitting therapy around work.
14-day free trial, no credit card
Make it yours
-
Tidy the frequency labels
The options read “Two or Three times a week” with capital letters in the template. Change them to sentence case so the buttons look consistent.
-
Ask about a referral
Add a yes-or-no question asking whether the patient has a doctor’s referral, which matters for insurance in many practices.
-
Add a file upload
Let patients attach a referral letter or scan results before the contact step, so the therapist can review them in advance.
Send every lead where your team works
Frequently asked questions
What does a physical therapy intake form usually cover?
It covers medical history, the injury or surgery, pain levels, medication and insurance. This template is the appointment request that comes first, and the intake follows after booking.
Can I add insurance questions?
Yes. Add a step asking for the insurer, or a yes-or-no question about coverage, before the contact details.
Where do new patient requests go?
Requests arrive by email, and Growform can send them to vcita, HubSpot, Keap or a Google Sheet at the same time.
What happens next?
-
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.
Start your free trial
Build multi-step forms just like this one. 14-day free trial, no credit card required.