In mybook®: Health
- Mon - Thu
- 8:00 am - 5:00 pm
MASTER CARD, VISA, ALL MAJOR CREDIT CARDS, DISCOVER, CASH, CHECK, DEBIT
Invisalign OrthodonticsPATIENT CONFIDENTIAL INFORMATION I. Patient Information: Name: Birthdate: Gender: Address: City: State: Zip: Home Phone: Cell: Email: Social Security #: Driver License: Employer: Phone: Address: Dental Insurance: Phone: Group #: If patient is not the primary subscriber, please fill out the following: Primary subscriber: Relationship to patient: Address (if different than above) Social Security #: Driver License: Birthdate: Employer: Phone: Address: Dental Insurance: Phone: Group #: II. Secondary Insurance Information: (Skip if not applicable) III. Dental History Please mark the following if apply: □ Routine check-up □ Cosmetic treatment (whitening, veneer) □ Teeth aligning (Invisalign/braces) □ Removal /replace teeth □ Gum bleeding □ Jaw pain □ Toothache □ Grinding □ Snoring □ Sleep Apnea □ Sensitive teeth □ Bad Breath □ Other: Last dental check-up/cleaning/Xray date: Last treatments: What do you like to improve about your dental health and appearance? IV. Emergency Contact: Name: Phone #: I hereby authorize payment directly to All Smiles Dental of the insurance benefits otherwise payable to me. I understand that I am financially responsible for any changes not covered by my insurance. I authorize dental care and release of any information necessary to bill my insurance carrier. In the event of default, I understand that I will be charged and I agree to pay all reasonable collection charges and/or attorney fees. Date: (Signature of the Insured/Responsible Party) FOR SIX-MONTH RECALL: Any changes your dental health: Signature of patient/responsible party: Date: MEDICAL HISTORY Patient: Age: 1. Please circle if you (patient) are currently having: pain, fever, cough, cold, flu, headache, fatigue, running nose Other condition: 2. Primary physician: Phone: 3. List of medication: Birth control pills? Please also include past experience to the following questions: 4. □ Yes □ No Pregnant. How long? 5. □ Yes □ No Nursing mother. 6. □ Yes □ No Weigh loss medications. (e.g. PhenFen): 7. □ Yes □ N Blood transfusion. 8. □ Yes □ No Tobacco use. 9. □ Yes □ No Recreational drugs. Please list: 10. □ Yes □ No Alcohol. 11. □ Yes □ No Allergic reaction to any medication or dental injection. 12. □ Yes □ No Skin reaction to metals, jewelry or latex. 13. □ Yes □ No Family history of diabetes, heart murmur, cancer, tumors. 14. □ Yes □ No IV/Oral Bisphosphonates for chemotherapy (i.e. Zometa, Fosamax, Actonel) 15. □ Yes □ No Hospitalized for any reason. Please check Yes or No: Y N Y N Y N Y N □ □ Artificial joint □ □ Cancer □ □ Emotional disorders □ □ High/low blood pressure □ □ Bleeding disorders □ □ Radiation/chemotherapy □ □ Psychiatric treatment □ □ Heart attack □ □ Glaucoma □ □ Fainting □ □ Arthritis □ □ Angina □ □ Cold sores □ □ Epilepsy □ □ Dizzy spells □ □ Heart murmur □ □ Fever blisters □ □ HIV/AIDS □ □ Thyroid pro
Dental ImplantsIf you are missing teeth, consider seeing an implant dentist. In general, dental implants are ideal for patients who a
BridgesDental bridges are highly durable and will last many years; however, they may need replacement or need to be re-cemented due to normal wear.
FillingsThere are many types of filling materials available, each with their own advantages and disadvantages. You and your dentist can discuss the best options for restoring your teeth. Composite fillings, along with silver amalgam fillings, are the most widely used today. Because composite fillings are tooth colored, they can be closely matched to the color of existing teeth, and are more aesthetically suited for use in front teeth or more visible areas of the mouth.
VeneersRussell Hamarnah, DMD, offers porcelain veneers at his Orlando office. Porcelain veneers can nearly instantly transform your smile. Veneers can improve the appearance of cracked teeth, crooked teeth, misshapen teeth, discolored teeth, gapped teeth, and teeth that are either too small or too large.
CrownsA crown (or cap) is a covering that encases the entire tooth surface, restoring it to its original shape and size. A crown protects and strengthens tooth structure that cannot be restored with fillings or other types of restorations.
Root Canal TreatmentRoot canal therapy is needed when the nerve of a tooth is affected by decay or infection. In order to save the tooth, the pulp (the living tissue inside the tooth), nerves, bacteria, and any decay are removed and the resulting space is filled with special, medicated, dental materials, which restore the tooth to its full function.
DenturesPatients missing several teeth in an arch often opt for partial dentures in Orlando. Partial dentures replace the missing teeth by filling in the large gap with artificial teeth. They also stabilize the arch and prevent the remaining teeth from shifting.
Tooth WhiteningRussell Hamarnah, DMD, is an Orlando dentist offering Zoom teeth whitening to patients who want a cleaner, whiter smile. Teeth bleaching is a simple process that changes the color of your teeth, brightening your smile.
Cosmetic DentistryRussell Hamarnah, DMD, an Orlando cosmetic dentist, offers a variety of cosmetic dentistry services designed to enhance the beauty of your smile. Whether you need a few cavities filled or need extensive dental work done, our Orlando cosmetic dentistry services are affordable without compromising quality.
General DentistryDr. Mauricio Mosquera was born and raised in Colombia, South America. He received a degree in General Dentistry from the Colombian Dental College known as Colegio Odontologico Colombiano, in Cali. After graduating, Dr Mosquera, worked as a family dentist in a rural area in Colombia providing social services. He then moved to Miami, Florida, where he attended his first residence program in advance dentistry and the following year did residency in the State of Washington. He practiced seven years working in a private practice in the southwest area of Washington State. In addition to his extensive dental training he also completed one year fellowship in implants at the Loma Linda University in California. He also is in process of completing his training in Temporomandibular disorders (TMD) and smile design at the Peter Dawson Academy. Dr. Mosquera is a member of the ADA,HDA, AAID, and the local Dental Society.
Teeth CleaningBrushing and flossing are of paramount importance to oral hygiene. Though bi-annual professional dental cleanings remove plaque, tartar, and debris, excellent homecare methods are equally valuable. Proper brushing and flossing can enhance the health of the mouth, make the smile sparkle, and prevent serious diseases.
Fluoride TreatmentPrevention also includes regular dental exams, cleanings, and x-rays. Sealants and fluoride are also great preventive treatments that help protect the teeth.
Dental SealantsAs a practice, we are true believers that preventative care and education are the keys to optimal dental health. We strive to provide “ dental health care ” vs. “ disease care ”. That’s why we focus on thorough exams – checking the overall health of your teeth and gums, performing oral cancer exams, and taking x-rays when necessary. We also know that routine cleanings, flossing, sealants, and fluoride are all helpful in preventing dental disease. Not only are we focused on the beauty of your smile, we’re also concerned about your health. A review of your medical history can help us stay informed of your overall health, any new medications, and any illnesses that may impact your dental health.
Oral Cancer ScreeningOral cancer screening: Check the face, neck, lips, tongue, throat, tissues, and gums for any signs of oral cancer.
Dental ExaminationDental radiographs (X-rays) are essential, preventative, diagnostic tools that provide valuable information not visible during a regular dental exam. Dentists and dental hygienists use this information to safely and accurately detect hidden dental abnormalities and complete an accurate treatment plan. Without X-rays, problem areas may go undetected.
X-raysDental X-rays produce a low level of radiation and are considered safe. Dentists take necessary precautions to limit the patient’s exposure to radiation when taking dental X-rays. These precautions include using lead apron shields to protect the body and using modern, fast film that cuts down the exposure time of each X-ray.
Oral and Maxillofacial Surgery
Flap SurgeryPocket elimination surgery – Pocket elimination surgery (also known as flap surgery) is a surgical treatment which can be performed to reduce the pocket size between the teeth and gums. Surgery on the jawbone is another option which serves to eliminate indentations in the bone which foster the colonization of bacteria.
Periodontal SurgeryIf the pockets do not heal after scaling and root planing, periodontal surgery may be needed to reduce pocket depths, making teeth easier to clean. Your dentist may also recommend that you see a periodontist (specialist of the gums and supporting bone).
Disclaimer: YP recommends that you always check with the business for pricing and availability of products and services. Although YP believes this information to be correct when posted, it is always subject to change by the business, so YP cannot guarantee the current accuracy of any product, service, inventory or pricing information shown here. YP’s display of a products or services list for a business does not imply any affiliation with, endorsement of or sponsorship between YP and either the listed business or any of the products or services included on such list.
- by jaybrad on 03/07/2013
- by miamigirl29 on 11/26/2009
Nice office....... Last place I went to was bad my friend liked this practice.
Kashlak Maria A DMD
6068 S Apopka Vineland Rd Ste 6, Orlando, FL Dentists, Oral & Maxillofacial Surgery, Physicians & Surgeons, Oral Surgery, Dental Clinics, Teeth Whitening Products & Services, Cosmetic Dentistry, Clinics, Dental Hygienists, Implant Dentistry, Periodontists, Endodontists, Orthodontists, Dental Labs, Prosthodontists & Denture CentersServices
Cosmetic & Family Dentistry
6900 Turkey Lake Rd, Orlando, FL Prosthodontists & Denture Centers, Implant Dentistry, Endodontists, Dental Insurance, Dentists, Pediatric Dentistry, Dental Clinics, Cosmetic Dentistry, Orthodontists, ClinicsServices(8)
Orlando Urgent Dental
251 E Michigan St, Orlando, FL Teeth Whitening Products & Services, Emergency Care Facilities, Dentists, Cosmetic Dentistry, Orthodontists, Pediatric Dentistry, Prosthodontists & Denture Centers, Clinics, Dental Clinics, Urgent CareServices(13)
Just a moment...