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Physiotherapy and chiropractic booking form template

A booking request for physio, chiropractic or sports massage: the service, the area, how they're paying and when.

Use this templateFree · no credit card
  • 12 questions
  • 2 pages
  • 5 min to fill in
  • Health and wellness
formkit.app/you/physio-chiro-booking
Physiotherapy and chiropractic booking

Book an appointment

Two short pages, about three minutes. Your practitioner asks about your health at the first appointment, not here.

12 questions · 2 pages
Try a theme

This is the real template. Fill it in, then make it yours.

The service, whether it's a first visit, the area to look at, how they're paying and the days that suit. Follow-ups skip the area question, and the insurer is asked for only when someone is paying through insurance. On Pro, a confirmation email is written and ready, and a person checks each one before it goes.

Who it’s for

Physiotherapy, chiropractic and sports massage clinics taking bookings from their website.

It asks for the area only, from a short list, and leaves the clinical questions for the first appointment.

Page by page

Every question in this template

The pages as a respondent meets them. Pick any question to open it in the live preview above.

  1. Page 1Questions8 questions
  2. Page 2When4 questions
  3. ThenRequest received

    We'll confirm your appointment by email within a working day.

    Conditional logic is already set up
What comes back

Every answer, in one place

Each response lands in your inbox as a card like this one, with an email to you if you want it. People who stop part-way are kept too, with the answers they gave.

  • Partial answers and drop-off by question, on every plan
  • CSV, JSON and PDF on every plan, Excel on Pro
  • Sheets, Slack, Notion, Airtable, HubSpot and webhooks on Pro
Maya OkaforPhysiotherapy and chiropractic booking · just nowNew
Your name
Maya Okafor
Your email
maya@northstar.co
Your phone number
+44 20 7946 0321
Which service would you like?
Physiotherapy
Is this a first visit or a follow-up?
First visit
Which area would you like looked at?
Back

and 6 more answers

From template to live form

Three steps, a couple of minutes

  1. Use this template1Make it your own copyIt becomes a draft in your account. Nothing you change touches the original.
  2. Reword, reorder, re-theme2Change anythingQuestions, pages, logic, theme and logo. It is an ordinary form from here on.
  3. formkit.app/you/physio-chiro-booking3Publish and shareYour own link, a QR code or an embed. Every answer lands in one inbox.
Make more of it

What this form can also do

Conditional and AI logicLogic that reads like a sentence, and AI that reads the answer.Explore AI repliesA personal reply to every response.Explore

Questions about this template

Can I use it for medical history or health records?

No. Formkit isn't built for medical or health records and doesn't offer HIPAA compliance, so this template stays at the front desk: details, the general reason for a visit and booking. Your practitioner goes through the rest in person.

Can it take insurance details?

It asks for the insurer's name only. Policy details are best taken at the appointment, not in a form.

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