The new Patient Appointment Request Form is the first step in a patient’s online scheduling experience. Designed to be flexible and intuitive, 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 section of the form so you can understand what patients see, how the form adapts, and what information is captured with each request.
- Patient Type: New or Returning selection impacts which appointment types appear later in the form, based on what the practice has enabled in their settings.
- Patient Info:
- First & Last Name
- Phone Number
- Date of Birth
- Street Address
- Apt, unit, etc.
- City
- State
- Zip Code
- Appointment Info: 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 provider.
- 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”.
- Message for the Office - Optional open text field where patients can include notes for the practice. This message appears with the appointment request.
- Insurance Information (Optional) - If you have Insurance Verification, we'll run verifications on patients who submit their insurance details at the time of booking and 3 days before their scheduled appointment. If completed, RevenueWell will attempt to run Insurance Verification (IV):
- If the patient is recognized in the system (name, DOB, email), and insurance info exists in the PMS, IV may still run even if this section is left blank. Insurance fields include:
- Insurance Provider (autocomplete dropdown)
- Subscriber First & Last Name
- Member ID
- Subscriber Date of Birth:
- If the patient is recognized in the system (name, DOB, email), and insurance info exists in the PMS, IV may still run even if this section is left blank. Insurance fields include:
- 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.
- Submit Button: Enabled once all required fields are complete. Missing fields will be highlighted.
- Practice Info Sidebar - This section pulls from practice settings and displays -
- Practice Name
- Reviews (from PC365)
- Address
- Phone Number
- Website
- Business Hours (from RevenueWell settings)
