Free New Patient Booking Enquiry template
Clinics: what the visit is for, referral and how it is paid for, the days and times that suit, and consent to call back.
9 questions · 3 pages · about 3 minutes to answer · fully editable after you start
A new patient who rings during a busy morning often hangs up before anyone answers. This booking enquiry lets them ask at any hour: what they would like to be seen for, a short note for the practitioner, whether they have a referral, how the visit will be paid for, which days and times suit them, and what matters most in choosing a clinic. It asks for no medical history, which belongs in your own intake once the appointment is made.
Replace [Your clinic, and the care you offer] on the opening page and [one business day] in the closing note. The opening line says the form is not for emergencies, so nobody waits on it for urgent help.
Template preview
This is a picture of every question as a respondent would see it, so nothing on it can be clicked or typed into. Use this template to get your own editable copy.
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Page 1 of 3
New patients
This form tells us what you would like to be seen for and when suits you, so we can offer you an appointment. It takes about 3 minutes. It is not for emergencies: if you need urgent medical help, call your local emergency number.
[Your clinic, and the care you offer]
Before your first visit
- Bring any referral letter and a list of the medicines you take
- Arrive a little early to settle in
Page 2 of 3
Your visit
Q1.What would you like to be seen for?
- A check-up
- An injury or pain
- An ongoing condition
- A second opinion
- Other…
Q2.Is there anything the practitioner should know before your visit? Please keep it brief and leave out detailed medical history.
Q3.Do you have a referral?
- Yes, from a GP
- Yes, from a specialist
- No referral
- Not sure if I need one
Q4.How will the visit be paid for?
- Private health insurance
- Public cover, such as Medicare
- Self-funded
- Workers compensation or another insurer
- Not sure
Q5.What matters most to you in choosing a clinic? Pick up to three.
- Getting in soon
- Seeing the same practitioner each time
- Being close to home or work
- Knowing the costs up front
- Weekend or after-hours times
Page 3 of 3
Your appointment
Q6.Which days suit you? Choose any that apply.
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
Q7.Which time of day suits you best?
- Morning
- Middle of the day
- Afternoon
- Evening
Q8.How can our reception team reach you?*
Q9.May the clinic contact you about an appointment?*
- I agree to the clinic contacting me about an appointment.
What happens next
Our reception team replies within [one business day] to offer you an appointment time.
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