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Dentist and clinics

Emergency dental request

A broken tooth, swelling or bleeding each show the right advice, and swelling shows a warning. Free to use with FillKite.

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Emergency dental request

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
Did it happen today?
Are you taking pain relief?

What is in this form

  • Your name (required)
  • Phone (required)
  • What has happened? (required)
  • Did it happen today? (required)
  • When did it happen? (required)
  • Are you taking pain relief?
  • Which one?

How the conditional logic works

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

  • A notice appears only when “What has happened?” is “Swelling”.
  • A notice appears only when “What has happened?” is “A knocked-out tooth”.
  • “When did it happen?” appears only when “Did it happen today?” is “No”.
  • “Which one?” appears only when “Are you taking pain relief?” 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 emergency dental request 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. A notice appears only when “What has happened?” is “Swelling”.

What fields does it have?

It has 7 fields: Your name, Phone, What has happened?, Did it happen today?, When did it happen?, Are you taking pain relief?, Which one?.

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