Dental Paradiso Medical History Login Retrieve my history ✖ Thank you for choosing Dental Paradiso. To ensure we are looking after all your dental needs, we appreciate you taking the time to complete this confidential form.PATIENT DETAILSGive name *Surname *Date of birth *Private Health Fund NameMember NumberIndividual reference number ? AddressSuburbStatePost CodeMobile *E-mail *Reason for the visit:Are you in pain?What is the nature of pain (please tick) throbbing dull ache sensitivity Intensity of pain 1 to 10 : 1 2 3 4 5 6 7 8 9 10 Lingering (please tick) : seconds minutes hours constant on and off Where in the mouth and face?Are you concerned with the appearance of your smile? Colour Shape Symmetry I don’t know and I’d like to find out Are you interested in a comprehensive smile assessment to explore possibilities in aesthetic improvements?How did you find out about us? Google Family/ friends Dentist Walked past Chat GPT, Gemini or AI Answers Other - please specify Emergency contact?Emergency contact numberPlease tick any of the following that apply to you:Any Heart Problems? * Yes No (Pacemakers, valve replacements please note down year of placement.)Excessive Bleeding? * Yes No Medication related or blood disorder – please specifyDo you have high or low blood pressure? Is it controlled? * High – Controlled High – Uncontrolled Low – Controlled Low – Uncontrolled No issues Do you have diabetes? * Yes No Have diabetes, Yes Type 1 Type 2 Not sure Rheumatic fever? * Yes No Are you pregnant? * Yes No Do you smoke? * Yes No Any allergies to anaesthetics? * Yes No Any allergies to penicillin / codeine? * Yes No Any allergies to latex? * Yes No Any kidney or liver problems? * Yes No Please specifyCancer history? * Yes No History of radiotherapy or chemotherapy? * Yes No Please specify the year and region of the bodyOsteoporosis? * Yes No Are you currently taking medication?HEP A/B/C or HIV? * Yes No Any other health conditions?List any medication you are currently taking:If you have a long list please notify the front desk and send to info@dentalparadiso.com.au for our records.Please indicate if any of the following apply to you:Do you snore regularly? Yes No Do you wear any sleep appliances? Yes No Do you often wake up unrefreshed? Yes No Do you wake up with tension around your face, neck or back? Yes No Consent for TreatmentI understand that the use of anaesthetics involves risks. I can be informed of a recital of any possible complications.I am responsible for payment of all services rendered on my behalf and on behalf of my dependants. I understand that payment is due at the time of service. Dental Paradiso reserves the right to share and disclose personal information with a Credit reporting agency in the event of non-payment.We kindly ask that 24 hours notice is given before cancellations or rescheduling. I agree that if 24 hours is not given beforehand, a fee may be charged and a deposit taken for future appointments. Would you like to receive oral care newsletters, special offers, and correspondence via email? Yes No Communication via SMS: Do you agree to receive convenient reminders via text? Yes No PAYMENT IS DUE AT THE TIME OF SERVICE. We have HICAPS facilities and accept all Visa, Mastercard, Eftpos & Cash. Please note: credit card payments will incur a 1.5% surcharge or AMX 2%. Submit
