Working example, built for Breakaway Chiropractic & Wellness

An instant confirmation, and an insurance number before the visit instead of after

Booking today is a two-step process: a request goes in, then someone from the front desk calls back to confirm. For a practice seeing 150 to 200 patients a week, that callback step is a meaningful chunk of front-desk time every day. This form confirms the moment someone submits, and adds a second message most booking widgets skip entirely: a plain-language estimate of what insurance is expected to cover, so a patient sees a number before the visit instead of a surprise on the invoice afterward.

What's real: the service list, the insurance carriers Breakaway accepts (Blue Cross, Aetna, United Healthcare, and VA through TriWest), and the practice hours are copied from breakawaychiro.com today. What's illustrative: the estimated dollar amounts in the insurance panel below are sample figures for demonstration, not a real benefits check against any patient's actual plan.

What I'd flag before this goes live

This replaces the callback, not the front desk. The confirmation you see below is what a patient would get the instant they submit, no waiting on someone to call back and confirm a time. The front desk still sees every request, they just aren't the ones creating the confirmation.
The insurance estimate is illustrative math, not a real eligibility check. A live version would need to either pull real coverage through a clearinghouse (e.g. Availity, Change Healthcare) via patient-authorized lookup, or work from Breakaway's own fee schedule and typical plan terms per carrier. What's shown here is a placeholder calculation using the accepted carrier list, meant to demonstrate the idea: a number appears before the visit, not after.
This is a request form, not a live booking calendar. It doesn't know which specific times are actually open, because it isn't connected to Breakaway's real schedule. A patient submits a service, day and time preference, and it reaches the front desk the same way a phone call would, just with the details and insurance carrier already on hand.
Nothing here actually sends anything. A real version would text or email the front desk the moment someone submits, and separately text or email the patient their confirmation and estimate. This demo just shows what both of those would look like.
Service list, accepted carriers and hours are copied from breakawaychiro.com today. If any of these change, this needs a one-line update to match, it won't drift out of sync on its own.