Health Referral Form
Simplify referrals from GPs, schools, community teams, and other care providers with this public Health Referral Form template. Collect referrer contact and address information, then add details and comments for up to four children in one submission. The Wizard adapts when no more children need to be added, keeping the referral concise. Customize the referral sources and questions, then connect submissions to your healthcare intake and review workflow.
This template is inspired by a customer story from Thrive Tribe, a healthy lifestyle provider that uses Plumsail Forms to collect referral and self-referral information and pass it through Power Automate into Dynamics 365 and Dataverse.
Structure and logic of the form
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The referral form is divided into steps using the Wizard container. Referrer contact and address information is collected first, followed by separate details for each child.
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The Referral Source field uses a predefined choice list for GP, primary care, secondary care, city care, community, and school referrals. Change the options in the field properties to match the services that can submit a referral.
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The Your Email field accepts only data matching a specified pattern. Choose from predefined patterns or create a custom one to validate referrer information.
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The Your Phone field accepts valid international phone numbers. In the field properties, you can select allowed countries.
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A referrer can submit information for up to four children. After each child, the form asks whether another child should be added. This is done with JavaScript code.
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The Wizard header and step labels are hidden with custom CSS, leaving a compact progress bar and navigation buttons for a cleaner referral experience.