Gerald V. Rizzo, DMD

445 Hackensack Street, Carlstadt, NJ 07072

T. 201.939.5770 F. 201.939.5771

RECALL MEDICAL HISTORY UPDATE:

Date:
Name:
Has your address changed?
YES No
New Address Change:
Has your home phone number changed?
YES NO
Please provide us with the following
Cell Phone #:
Email Address:
Has your Dental Insurance carriers changed?
YES NO

*****If YES, please provide the receptionist with a copy of your NEW insurance card.

Since your last recall appointment:

Are there been any changes in your medical history?
YES NO
Since last visit, have you been diagnosed with a heart murmur?
YES NO
Have you had any recent surgeries?
YES NO
If YES, briefly explain:
Are you taking any NEW medications?
YES NO
If YES, please list them:
Have you developed any NEW allergies?
YES NO
If YES, briefly explain:
Are you currently under the care of a Physician?
YES NO
If YES, briefly explain: