About this template
Managing patient capacity is a major challenge for modern Direct Primary Care (DPC) clinics aiming to maintain high-touch, accessible care. This DPC Waitlist Sign-up Google Form template helps independent practices capture prospective patient inquiries, understand individual membership interests, and prioritize clinic outreach without drowning in administrative overhead.
Designed specifically for healthcare providers transitioning to or operating on a membership model, the form collects essential contact details alongside specific medical needs and referral channels. Clinics can use the structured responses to evaluate practice capacity, tailor follow-up communications, and maintain an organized, compliant queue of interested patients.
With Doc2Form, you can instantly turn this template into a live Google Form, customize the fields to match your clinic's tier structure, and begin onboarding new patients seamlessly.
Key features
- Capture prospective DPC patient contact info in one organized queue.
- Understand individual membership interests and specific medical needs upfront.
- Track referral sources to see how patients discovered your practice.
- Easily embed or share via email to prospective patients visiting your site.
- Fully customizable via Google Forms to match your clinic's branding and tiers.
Use cases
- New Direct Primary Care clinics building their initial patient panel.
- Established DPC practices managing a capped membership waitlist.
- Concierge medical practices screening prospective members.
- Family medicine clinics transitioning to a subscription-based model.
What this form collects
- Full Name (Short answer)Please enter your first and last name.
- Phone Number (Short answer)Enter the best phone number for our team to reach you.
- Email Address (Short answer)We will use this email for practice updates and membership information.
- How did you hear about our practice? (Dropdown)Select the option that best describes how you found us.
- Medical Needs & Membership Interest (Paragraph)Briefly share what you are looking for in a primary care provider and which membership tier interests you most.
- Contact & Subscription Consent (Multiple choice)Do you consent to receive practice updates and waitlist communications via phone, text, and email?
FAQ
How do I use this DPC waitlist template?
With Doc2Form, you can instantly generate this template as a ready-to-use Google Form with a single click, then share the link directly with prospective patients.
Can I customize the membership interest questions?
Yes! Once the form is in your Google Drive, you can freely edit, add, or remove any questions to reflect your specific practice tiers and pricing.
Where are the waitlist submissions stored?
All responses automatically populate a connected Google Sheet, giving you a centralized, searchable roster of prospective patients.
Is this form template free to use?
Yes, the template is completely free to convert and deploy using Google Forms.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.