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

  • Please note:
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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.):
      Tell Us More

      Phone: 717-235-3871

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