New Patient Medical History Form

If you have an appointment as a new client to our practice, please follow the instructions below.

Please print all pages, complete all sections and bring it with you to your first appointment.  If there are any areas that you are not sure about, please leave it blank and we will review it with you. Please also print the next form below, Consent to Treatment and Privacy, and complete it as well.

Welcome to our practice! Looking forward to seeing you soon and having you as part of our Dentistry on Yorkville family.

Consent to Treament and Privacy Form

Please print and complete the form and bring it with you to your appointment.

Transfer of Records and X-rays

Please print this form and complete the blanks in order to have any current records sent to our office prior to your appointment. The form needs to be sent to your former dentist.

Invisalign Consent Form

Please print this form and sign where indicated. Please be sure to bring the completed form, along with any questions, to your next appointment.

ZOOM Whitening Consent Form

Please print this form and initial and sign where indicated. Be sure to have this form with you at your consultation appointment.

ZOOM Whitening Pre and Post Treatment Instructions

This form has the information regarding the procedures to follow prior to your ZOOM Whitening treatment, as well as the instructions for the 48 hours after.  Please print this form and keep it handy for reference.