Lead capture pattern, built
A new patient form that checks insurance before the visit.
What a patient pays depends on their plan and whether the practice is in network, which is worth knowing before anyone sits in the chair. This pattern collects that detail up front, so the front desk can check benefits before the first visit.
- One build price for your new site, from $1,500
- $0 setup, no patient-intake software fee
- 30-day guarantee: no benefit, no bill
How the form works
Reason, insurance, contact, one scheduling task.
The questions it asks
The visitor picks a reason for the visit, a checkup, a specific problem, or a cosmetic interest, then a preferred appointment window. Insurance status follows, with a carrier name if they have coverage, along with standard new-patient details like name and contact information.
The logic behind the answer
No price shows anywhere, since real cost depends on the exact procedure and what the plan covers once it is checked. The form's job is to gather enough insurance detail that the front desk can start verifying benefits before the patient ever walks in.
Where the lead goes
The request reaches whoever handles scheduling and insurance verification, with the carrier name attached, so that check can begin before the appointment rather than in the waiting room on the day itself.
What happens when nobody picks up
A same-day acknowledgment goes out either way, confirming the office received the request, since new-patient research often happens in the evening or on a weekend and should not sit unanswered until Monday.
Why insurance up front works for a dental practice
Verification can happen before the visit, not in the chair
Asking for insurance details at intake, instead of at check-in, gives the front desk time to check benefits and coverage ahead of the appointment rather than during it.
Reason for visit and insurance are asked separately
A patient with acute pain can be flagged for a sooner appointment than someone booking a routine checkup, and keeping those two questions distinct makes that triage possible.
It collects only what scheduling actually needs
New-patient health information is handled carefully under rules like HIPAA in the US and PIPEDA or PHIPA in Canada, so the form asks only what scheduling and insurance verification require, not a full medical history.
A same-day acknowledgment keeps evening research from going cold
Dental research often happens outside office hours, and a patient in pain who hears nothing back by the next morning tends to just call the next practice on their list.
How we build this into your site
01
We learn your real intake fields and common carriers
We work from what your front desk actually needs at intake and which insurance carriers you see most often, so the form's fields match your real verification process.
02
We build and test the new-patient form
The form ships as a real page on your new site, tested on a phone first, since people often search for a new dentist and fill out an intake form in the same short session.
03
We connect it to scheduling and verification
The finished request reaches your front desk's scheduling workflow with the insurance detail attached, so verification can start right away rather than waiting on a callback.
New patient form with insurance, answered
No. It starts the office's own verification process sooner. Some plans and questions still need a direct call, but this gets that process moving before the visit.
The form still accepts the request. It simply flags that detail so the front desk knows to discuss payment options rather than insurance coverage at the appointment.
The pattern sends a same-day acknowledgment regardless of when the request comes in, with a specific appointment time confirmed once the office reviews it.
The form is built to collect only what scheduling and insurance verification require, consistent with health privacy rules like HIPAA in the US and PIPEDA or PHIPA in Canada.
Dental practices and similar healthcare providers where insurance status affects patient cost and scheduling. We adapt the intake fields to your practice's real process.
Want this built for your practice?
Tell us your real intake fields and the carriers you see most, and we will scope a new patient form around your process as part of a one-time website build. A proposal is back in your hands within one business day.