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Home
About Us
- Dr. Jonelle Crichton
- FAQ
Pediatric Dentistry
Orthodontics
Forms
- Pediatric Intake Form
- Orthodontic Intake Form
Contact Us

Pediatric Patient Intake Form

Please fill out the form below to assist us in completing your check in more efficient and paperless.

Step 1 of 3

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Patient Last Name*
Patient First Name*
Sex
Date of Birth
AB Health Care Number
Email Address*
Mobile Number*
Alternate Number
Street Address
Apt#/ Suite#:
City
Province
Postal Code
If patient is under the age of 18, who is the legal guardian? Relationship:
Last Name
First Name
Phone Number
Address

INSURANCE COVERAGE
- Name of Company
- Group/Policy #
- ID/Certificate #
- Subscriber DOB
- Name of 2nd Insurance Company
- Group/Policy #
- ID/Certificate #
- Subscriber DOB
Health problems that you may have, or medication(s) that you may be taking, could have an important interrelationship with the surgery and/or sedation you will receive.
Are you taking any medications, pills, or drugs?*
- Yes
- No
If yes, please list:
Do you have any known allergies?*
- Yes
- No
If yes, please list:
Do you use any herbal supplements?*
- Yes
- No
If yes, please list:
Do you drink alcohol?*
- Yes
- No
If yes, how many drinks per week?
Do you use any controlled substances?*
- Yes
- No
If yes, please list:
Do you smoke regularly?*
- Yes
- No
If yes, how much per day?
Are you being treated for any medical condition at the present time or have you been treated within the past year?*
- Yes
- No
If yes, please explain:
Has there been any change in your general health in the past year?*
- Yes
- No
If yes, please explain:
Do you have a bleeding problem or bleeding disorder?*
- Yes
- No
Are there any disease or medical problems that run in our family? (Diabetes, cancer or heart disease)*
- Yes
- No
If yes, please explain:
Have you been diagnosed with Sleep Apnea?*
- Yes
- No
If yes, do you use a CPAP machine?*
- Yes
- No
Do you get chest pain or shortness of breath when you climb up 2 flights of stairs or walk 4 blocks?*
- Yes
- No
Have you or a family member ever experienced an adverse reaction to sedation medications or general anesthesia?*
- Yes
- No
If yes, please explain:
Do you have, or have you had, any of the following? Check (√) yes if applicable:
- Acrylic Allergy
- AIDS/HIV Positive
- Amoxicillin Allergy
- Anaphylaxis
- Anemia
- Angina
- Arthritis/Gout
- Artificial Heart Valve
- Artificial Joint
- Aspirin Allergy
- Asthma
- Blood Disease
- Blood Transfusion
- Breathing Problem
- Bruise Easily
- Cancer
- Chemotherapy
- Chest Pains
- Clindamycin Allergy
- Codeine Allergy
- Cold Sores/Fever Blisters
- Cortisone Medication Allergy
- Diabetes
- Drug Addiction
- Emphysema
- Epilepsy or Seizures
- Excessive Bleeding
- Excessive Thirst
- Fainting Spells/ Dizziness
- Frequent Headaches
- Glaucoma
- Hay Fever
- Heart Attack/Failure
- Heart Disease
- Heart Pacemaker
- Heart Trouble
- Hemophilia
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Herpes
- High Blood Pressure
- Hives or Rash
- Hypoglycemia
- Irregular Heartbeat
- Kidney Problems
- Latex Allergy
- Leukemia
- Liver Disease
- Local Anesthetics Allergy
- Low Blood Pressure
- Metal Allergy
- Pain in Jaw Joints
- Parathyroid Disease
- Penicillin Allergy
- Radiation Treatments
- Renal Dialysis
- Rheumatism
- Sinus Trouble
- Stroke
- Taking Birth Control
- Thyroid Disease
- Tuberculosis
- Tumors or Growths
- Ulcers
- Yellow Jaundice
Females > 12 years Are you pregnant?
- Yes
- No
Due Date
Have you ever had any serious allergy, illness or accident not listed above?*
- Yes
- No
If yes, please explain:
Please list previous surgeries:

To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information may be dangerous to my (or patient's) health. It is my responsibility to inform Bloom Dentistry of any changes in medical status.
Signature of Patient*
Date*
DD slash MM slash YYYY
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Signature of Dentist
Hidden
Date
DD slash MM slash YYYY

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Contact Leduc

Orthodontic & Childrens Dentistry
Telephone: 780-612-9762
#201 6209 – 50 St
Leduc, AB
Mon-Fri: 8:00– 4:00
Sat: Closed
Sun: Closed

Contact Edmonton

General & Pediatric Dentistry
Telephone: 780-612-9762
202- 511 Mistatim Way
Edmonton, AB
Mon-Fri: 8:00– 4:00
Sat: Closed
Sun: Closed

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Bloom is dedicated on providing exceptional children’s dentistry and orthodontic treatments for all ages.

CONTACT US

#201 6209 - 50 St Leduc, AB
Phone: 780-612-9762
Email: info.pedo@bloomdentistry.ca

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FREE VIRTUAL CONSULTATION
Upload a few images of your teeth and we'll propose a preliminary treatment plan ASAP. No appointment necessary.
Name
Email
Phone
Select Office
Comments

- SAY CHEESE!
  Before we can recommend a treatment plan, we need to take a peek at your teeth.
  Let’s warm up with a head-on selfie. Bite down on your back teeth and smile as wide as you can!
  Do your best to match the example photo.
- SAY CHEESE!
  Drop files here or
  Accepted file types: jpg, png, jpeg, Max. file size: 2 MB, Max. files: 1.

- LEFT SIDE
  Great shot! Next up, we need to see your smile from the left side.
  Still biting down on your back teeth, pull your cheek back either with your fingers or using a spoon.
  Do your best to match the example photo.
- LEFT SIDE
  Drop files here or
  Accepted file types: jpg, png, jpeg, Max. file size: 2 MB, Max. files: 1.

- RIGHT SIDE
  These are coming out great! Let's try the same shot, this time from the right.
  Make sure you're biting down on your back teeth!
  Do your best to match the example photo.
- RIGHT SIDE
  Drop files here or
  Accepted file types: jpg, png, jpeg, Max. file size: 2 MB, Max. files: 1.

- UPPER TEETH
  Next up, we need to see your upper teeth from below.
  Open wide! You may want to enlist the help of a friend for this one.
  Do your best to match the example photo.
- UPPER TEETH
  Drop files here or
  Accepted file types: jpg, png, jpeg, Max. file size: 2 MB, Max. files: 1.

- BOTTOM TEETH
  Almost done: just one shot left! This time, we need to see your lower teeth.
  Once you've taken all of your photos, click Request Consult to send your shots to our doctor!
- BOTTOM TEETH
  Drop files here or
  Accepted file types: jpg, png, jpeg, Max. file size: 2 MB, Max. files: 1.

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