Scheduling: Preview Appointment Request Form

The Patient Appointment Request Form is the first step in a patient’s online scheduling experience. Designed to guide them through each step of the process, this form dynamically adjusts based on your practice’s settings and the patient’s responses. In this article, you’ll get a detailed look at each step of the form so you can understand what patients see, how the form adapts, and what information is captured with each request.

The Appointment Request form now includes an AI-powered Insurance Card Reader. Instead of manually entering insurance information, patients can simply scan or upload their insurance card. RevenueWell automatically extracts the insurance details, reducing manual entry errors and improving the accuracy of patient information. For practices using AI Insurance Verification, submitted insurance information is automatically used to begin the eligibility verification process.

1. Visit & Time: Patient will first indicate if they are New or Returning. This selection impacts which appointment types appear, based on what the practice has enabled in their settings.
   
   There are two scheduling paths, depending on how the appointment type is configured:
   • Simple Appointment Request -Triggered when PMS Calendar Availability is turned OFF. The form asks patients for preferred days/times (Morning, Afternoon, Evening), based on the practice’s availability settings. Multiple preferences can be added using “+ Add another day/time”.

   • PMS-Based Scheduling Request -

     • Triggered when PMS Calendar Availability is turned ON.
     • Patients choose a specific date and time from available slots pulled from the PMS (based on operatory availability).
     • If configured, patients can also select a preferred primary provider.

     Message for the Office - Optional open text field where patients can include notes for the practice. This message appears with the appointment request.
     

2. Patient Info: Patients enter their basic contact and demographic information, including -
   • First & Last Name
   • Email
   • Phone Number
   • Date of Birth
   • Street Address
   • Apt, unit, etc.
   • City
   • State
   • Zip Code
     

3. Insurance Information -For offices without Insurance Verification, insurance information will simply be collected in this step. For those with Insurance Verification, completing this step will trigger IV to perform a verification.

   To begin, customers will choose if they plan to use insurance or self-pay. If they select Self-Pay, they will be able to continue to review their request. 
   
   If they use Insurance, they will have the option to scan a photo, upload a file, or type in their Insurance Information. 

   Depending on what is chosen, insurance fields may include:

   • Insurance provider
   • Subscriber's first and last name
   • Member ID
   • Subscriber's date of birth
     
     
4. Compliance & Submission
   • Consent Checkbox: Must be checked before submission; confirms the patient agrees to be contacted.
   • CAPTCHA: Verifies the form isn’t being submitted by a bot.
   • Confirm Appointment/Submit Request Button: Enabled once all required fields are complete. Missing fields will be highlighted.
     
5. Practice Info Sidebar - This section pulls from practice settings and displays location information for patients to view as they submit their appointment information.
   • Practice Name
   • Reviews (from PC365)
   • Address
   • Phone Number
   • Email
   • Website
   • Business Hours (from RevenueWell settings)

Learn more about how our system determines the source of truth for insurance information in our Insurance Information Collection article.