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Dentist and clinics

Dental appointment

A check-up asks when you last visited, and pain opens a question about how bad it is. Free to use with FillKite.

Live demo

Dental appointment

Fill it in and press the button to see how it behaves. Nothing you type is saved or sent.

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Test mode: you can try this form, but nothing you send is saved or passed on.

Your name
Are you a new patient?

What is in this form

  • Your name (required)
  • Email (required)
  • Phone (required)
  • Reason for visit (required)
  • When was your last visit?
  • How bad is the pain?
  • Are you a new patient? (required)
  • Who referred you? (optional)
  • Preferred date (required)
  • Preferred time

How the conditional logic works

This form shows or hides fields as people answer, so everyone sees only what matters to them.

  • “When was your last visit?” appears only when “Reason for visit” is “Check-up and clean”.
  • “How bad is the pain?” appears only when “Reason for visit” is “Toothache”.
  • A notice appears only when “How bad is the pain?” is more than “7”.
  • “Who referred you? (optional)” appears only when “Are you a new patient?” is “Yes”.

Use it on your site

  1. Install FillKite free from WordPress.org.
  2. Download this form with the button above.
  3. Go to FillKite → Import → From a FillKite file, choose the file and import it.

Questions

About this form

Is the dental appointment form free?

Yes. It works with the free FillKite plugin, and you can download it and change it as you like.

Is anything I type saved?

No. This demo runs in test mode: FillKite checks your answers like a real form, but nothing is saved and no email is sent.

How do I use this form on my site?

Install FillKite, download the form with the button on this page, then go to FillKite → Import → From a FillKite file and choose the file. After importing, open it in the builder, change anything you like and add it to a page.

Does this form use conditional logic?

Yes. 4 fields or notices show only when earlier answers call for it. “When was your last visit?” appears only when “Reason for visit” is “Check-up and clean”.

What fields does it have?

It has 10 fields: Your name, Email, Phone, Reason for visit, When was your last visit?, How bad is the pain?, Are you a new patient?, Who referred you? (optional) and more.

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Conditional logic. A child’s form asks for a parent, and clear aligners open a question about teeth already moved.

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