Healthcare and wellness

Insurance details

Insurance fields show only if the patient is insured, and policyholder fields only if it is someone else. Free to use with FillKite.

Live demo

Insurance details

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

What is in this form

Your name (required)
Email (required)
Do you have health insurance? (required)
Insurance company (required)
Policy number (required)
Who holds the policy? (required)
Policyholder’s name (required)
How would you like to pay?

How the conditional logic works

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

“Insurance company” appears only when “Do you have health insurance?” is “Yes”.
“Policy number” appears only when “Do you have health insurance?” is “Yes”.
“Who holds the policy?” appears only when “Do you have health insurance?” is “Yes”.
“Policyholder’s name” appears only when “Do you have health insurance?” is “Yes” and “Who holds the policy?” is “Someone else”.
“How would you like to pay?” appears only when “Do you have health insurance?” is “No”.

Use it on your site

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

Questions

About this form

Is the insurance details 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. 5 fields or notices show only when earlier answers call for it. “Insurance company” appears only when “Do you have health insurance?” is “Yes”.

What fields does it have?

It has 8 fields: Your name, Email, Do you have health insurance?, Insurance company, Policy number, Who holds the policy?, Policyholder’s name, How would you like to pay?.

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Free on WordPress.org

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