Form 1 of 4
New Patient Information
Welcome! Please tell us about yourself so we can give you the best care possible.
Form 2 of 4
Dental Patient Medical History
This information helps Dr. Haywood provide safe, personalized care. All records are strictly confidential.
Form 3 of 4
Biological Dental Wellness Checklist
Dr. Haywood practices holistic, biological dentistry. This form is required. Please answer all questions as completely as possible — it directly shapes your care plan.
Form 4 of 4 — Final Step
Privacy Statement & Signature
Please read our privacy commitment below, then sign and submit your completed forms.
The offices of Dr. Steven Haywood insure the privacy of all your healthcare information. We take special precautions to guard your records and the information you give to us in all forms with the utmost in care and professionalism.
The government mandates that we inform you of your rights when it comes to the protection of your privacy. In our offices, we have always strived to provide our care in the most ethical manner allowing our convictions and principles to be our guide.
Your conversations with our staff will be conducted with all reasonable efforts to insure that personal information is as private as you, the client, want it to be.
Your medical records will be in our treatment rooms only when they are being used for your direct care in our office. No one has the right to see or review your records unless specifically authorized by you.
Your dental insurance will be transmitted by mail and not by electronic means. If you prefer, the office will give a completed claim form to you at the end of your appointment. Please check it for any errors, then mail to your insurance company. In this way, we are in compliance with the HIPAA privacy act and your privacy is protected.
Any records released from this office must be preceded by a written authorization from you. Records transferred to consulting doctors will be upon your authorization either verbal or written.
Any personal information collected by our offices will be kept in secure areas and under lock and key if transferred to either of our offices.
Your electronic records are always in the possession of Dr. Haywood and are never transferred over the Internet or by modem on non-secure pathways.
You have the right to privacy in your financial dealings with this office and we will strive to arrange your payments in the treatment rooms or in one of our several private offices for your convenience.
Thank you for being our loyal client. Serving you is the reason we are here.
Type your full legal name to sign
Digital signature — legally equivalent to a handwritten signature
I authorize release of information regarding my dental treatment to my insurance carrier. I agree to be responsible for payment on services rendered during my ineligible insurance period or any balance not paid by the insurance carrier. I understand that insurances are billed as a courtesy and that I am ultimately responsible for all costs of treatment and ultimately for reading and understanding my insurance plan and limitations.
Forms Submitted!
Thank you! Your patient intake forms have been received by Southern York Smile Care. Our team will review them before your appointment. If you have any questions, please call us at (717) 235-3871.
SEE YOU SOON!