Orthotics and Prosthetics Appointment Request Form: Fields That Matter

Overview

An O&P appointment form should help the office answer:

It does not need to become the clinical chart.

• Who should we contact?
• Which location works?
• What broad service category is involved?
• Is this a new or returning patient?
• Is a referring provider involved?
• When should the office call?

Field 1: Patient / requester name

Collect the name needed to make contact.

If a parent, caregiver or professional is submitting for someone else, allow:

Union O&P currently asks this distinction explicitly.

• requester name;
• relationship to patient.

Field 2: Phone and email

Collect:

If the clinic uses SMS, obtain explicit consent under the clinic’s reviewed workflow.

• phone;
• email;
• preferred contact method.

Field 3: Preferred office location

Make location required when the clinic has multiple offices.

Fresh O&P forms use location as a core routing field.

Field 4: Broad service category

Useful options can include:

Do not ask the patient to diagnose themselves.

• orthotics;
• prosthetics;
• pediatrics;
• cranial remolding;
• therapeutic footwear/pedorthics;
• other service genuinely offered;
• not sure.

Field 5: New or returning patient

This can help the office route:

The clinical system should still own the patient identity after handoff.

• new evaluation;
• follow-up;
• adjustment;
• established patient issue.

Field 6: Referring provider

Optional:

Do not collect clinical referral documentation in this general marketing form.

• provider name;
• practice/organization;
• no referral yet;
• not sure.

Field 7: Preferred appointment timing

Use:

If the clinic has real bookable slots, the business can expose them.

If appointment suitability requires review, label the conversion Request Appointment rather than Confirmed Appointment.

• preferred days;
• morning/afternoon;
• best time to call;
• flexible.

Field 8: General reason for contact

Use a broad, nonclinical field such as:

What can our office help you with?

Keep it short.

Avoid prompting for a detailed medical history.

Field 9: Provider / medical-professional flag

Union O&P asks whether the submitter is a medical professional.

That can help route the request into:

• patient scheduling;
• provider relationship;
• referral support.

What not to collect in a basic appointment request

Avoid:

Move those into the clinic’s approved secure clinical workflow after the office accepts the request.

• detailed diagnosis;
• medical history;
• full insurance data;
• insurance card images;
• prescriptions;
• physician notes;
• clinical photos;
• protected medical documents.

Appointment request vs clinical intake

Confirmation message

Use:

Thanks. We received your appointment request. Our team will review your preferred location, service category and contact details and reach out about the next step.

Avoid:

Your treatment is scheduled.

unless the clinic has actually confirmed the appointment.

Keep the first form light enough to use and narrow enough to protect the boundary

The public website should start the relationship.

Clinical intake should begin in the system built for clinical care.

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Questions businesses ask