- My Forms at Home

Welcome to our family!
We are thrilled to have you as a patient at Kennedy Heights Dental Centre. We want to ensure your experience with us is unforgettable. To help us understand how to meet your specific treatment goals, please fill out these questions so we can know you better.

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

THE STORY OF YOUR MOUTH:

MEDICAL HISTORY:

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance