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Patient Forms

Patient Forms for Your Southern York Dentist

Please download the forms below, fill them out, and bring them to your scheduled appointment with

  • Payment Options
  • Health History
  • Sedation Consent
  • Esthetic Evaluation
  • Privacy Statement


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      Name:
      Email:
      Phone:
      Address:
      Tell us your story, how may we help?
      Are you a Existing Patient?:
      YesNo
      Preferred time(s) to call?:
      MorningNoonAfternoonEvening
      Preferred day(s) of the week for an appointment?:
      Any DayMondayTuesdayWednesdayThursdayFriday
      Preferred time(s) for an appointment?:
      Any TimeMorningNoonAfternoonEvening
      Please describe the nature of your appointment (e.g., consultation, check-up, etc.):
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      Phone: 717-235-3871

      Address: Southern York Smile Care 4 S Main St Shrewsbury PA 17361

      Glimpse of Our Practice

      picture of the front of our office building showing the entrance
      picture of the front of our office building showing the entrance
      picture of one of our dental examination rooms with a dental chair and red walls
      picture of one of our dental examination rooms with green and yellow walls and a dental chair
      one room in our office with Dr. Haywood's achievements and a table
      picture of a hallway in our office with stairs
      interior of our dental office showing the front desk and the entrance to the waiting room
      picture of our dental office showing the front desk area and the entrance to the waiting room
      picture of our waiting room showing the view from the front desk
      picture of our waiting room showing the couch and two chairs
      angle of our waiting room facing the windows
      an angle of our waiting room showing chairs, a couch, and a picture of a smile on the wall