Home > Resources > Patient Forms

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 Dr. Haywood. Having your forms completed upon check-in ensures a smooth and timely start to your visit with us. If you have any questions about the forms, please call our office at (717) 235-3871.


Please note: You will need Adobe Reader to view and download these forms. You can download Adobe for free by clicking here.

New Patient Online Offer

Free second opinion ($125 Value)

Contact us today for details

Make an appointment

Contact Us

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

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