Gerald V. Rizzo, D.M.D.

445 Hackensack Street, Carlstadt, NJ 07072

T. 201-939-5770 F. 201-939-5771

www.smilesbyrizzo.com

Welcome To Our Practice!

Date:
Patient:
Last
First
Initial
Birthdate:
Age Sex M F Status Single Married Other
Home phone:
Cell:
Best # To Reach You:
E-mail:
Street Address:
City:
State:
Zip:
Employed by:
Occupation:
Business Address
Business Phone
Spouse/Parent name
Spouse/ParentBirthdate
Spouse/Parent employed by
Occupation
Business Address
Business Phone
Relationship to Patient
Social Security #
Spouse/Parent Social Security #
Name of Dental Insurance Company
Group Number
ID Number:
Group Plan:
Insurance #:
In case of emergency, who should be notified?
Phone
Whom may we thank for referring you?

MEDICAL HISTORY

Physician’s name
Date of Last Physical
Have there been any changes in your general health in the past year?
Are you under the care of any physician?
If so, what for?
Do you have any drug allergies or have you ever had an adverse reaction to any medication?
If so, what?
Have you ever responded adversely to medical or dental treatment?
Are you taking any medication at this time?
If so, what?
Is there anything we should know about your medical history?
Women: Do you suspect you are pregnant? YES NO Are you nursing? YES NO

Have you ever had any of the following? (Check boxes that apply!)

**IT IS IMPERIVIVE THAT WE KNOW THESE THINGS!!**

  • Heart Problems
  • High Blood Pressure
  • Low Blood Pressure
  • Circulatory Problem
  • Nervous Problems
  • Radiation Treatment
  • Artificial Heart Valves or Joints
  • Recent Weight Loss
  • Back Problems
  • Diabetes
  • AIDS/Immunosuppressive
    Disease
  • Venereal Disease
  • Epilepsy
  • Headaches
  • Hepatitis, Jaundice,or Liver Disease
  • Cancer
  • Psychiatric Care
  • Chronic Diarrhea
  • Allergies to Anesthetics
  • Allergies to Medicine/Drugs
  • Chemical Dependency
  • Bone Density Medications
  • Blood Disease
  • Arthritis
  • Special Diet
  • Swollen Neck Glands
  • Rheumatic Fever
  • Sinus Problems
  • Stroke
  • Ulcer
  • Hemophilia
  • General Allergies
  • Respiratory Disease
  • Difficulty Breathing
*If there is anything else that we should know about your medical or dental history, please use this space to do so, this is so that we may better help you:
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.
Signature of Patient: (Parent or Guardian, if minor)
Date:

Fees & Payments

We make every effort to keep down the cost of dental treatment, you can help by paying upon completion of each dental visit. Other arrangements can be made with our front desk depending on your circumstances. Please remember that insurance is considered a method of reimbursement, it is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amounts, coinsurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney fees, and court costs.
Signature of Patient: (Parent or Guardian, if minor)
Date:
This signature on file is my authorization for release of information necessary to process my claim with my insurance company. I hereby authorize payment to this doctor named of the benefit otherwise payable to me.
Signature of Patient:
Date: