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Old Metairie Orthodontics

Address:
Metairie
701 Metairie Rd, Ste 1A-204
Metairie, LA 70005

Phone:
(504) 835-1349

Hours:
Mon: 9:00 AM–5:00 PM
Tue: 9:00 AM–4:00 PM
Wed: 7:00 AM–4:00 PM
Thu: 9:00 AM–5:00 PM
Fri: 9:00 AM–2:00 PM


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Title
Sex
Marital Status
Does this policy have orthodontic benefits
Does this policy have orthodontic benefits_2
Local Anesthetics (Novocain, Lidocaine, Xylocaine)
Bone Fractures or major injuries
Heart Defects, Heart Murmur, or Rheumatic Heart Disease
Tonsil or Adenoid Condition
Birth defects or hereditary problems
Any Injuries to Face, Head, or Neck
Aspirin
Metals (Jewelry, Clothing Snaps)
Endocrine or Thyroid Problems
Kidney Problems
Cancer, Tumor, Radiation Treatment, or Chemotherapy
Stomach Ulcer, Hyeracidity, or Acid Reflux
Plant Pollens
Immune System Problems
History of Osteoporosis
Other Substances
Polio, Mononucleosis, Tuberculosis, or Pneumonia
History of Eating Disorder (Anorexia, Bulimia)
Supernumerary (Extra) or Congenitally Missing Teeth
High or Low Blood Pressure
Any Sensitive or Sore Teeth
Chest Pain, Shortness of Breath, Tire Easily, or Swollen Ankles
Teeth Treated With Root Canals or Pulpotomies
Skin Disorder (Other Than Common Acne)
History of Speech Problems or Speech Therapy
Asthma, Sinus Problems, or Hay Fever
Abnormal Swallowing (Tongue Thrust)
Tooth Grinding or Clenching
Soreness in Jaw Muscles or Face Muscles
TMJ or TMD Problems/Treatment
Broken or Missing Fillings
Have you ever had any serious trouble associated
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?
Latex (Gloves, Balloons)
Arthritis or Joint Problems
Penicillin
Diabetes or Low Sugar
Other Antibiotics
Ibuprofen (Motrin, Advil)
Acrylics
Animals
Foods
Gonorrhea, Syphilis, Herpes, or Sexually Transmitted Diseases
AIDS or HIV Positive
Hepatitis, Jaundice, or Other Liver Problems
Seizures, Fainting Spells, or Neurologic Problems
Mental Health Disturbance or Depression
Vision, Hearing, or Speech Problems
Permanent or Extra (Supernumerary) Teeth Removed
Chipped or Injured Primary or Permanent Teeth
Excessive Bleeding or Bruising, or Anemia
Bleeding Gums, Bad Taste, or Mouth Odor
Jaw Fractures, Cysts, or Infections
Angina, Arteriosclerosis, Stroke, or Heart Attack
Gum Boils, Frequent Canker Sores or Cold Sores
Well-Balanced Diet
Frequent Headaches or Migraines
Difficulty Breathing Through the Nose
Frequent Ear Infections, Colds, or Throat Infections
Food Impaction Between the Teeth
Mouth Breathing Habit or Snoring at Night
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Frequent Mouth Breathing
Teeth Causing Irritation to Lip, Cheek, or Gums
Clicking or Locking in Jaw Joints
Ringing in Ears, Difficulty in Chewing or Opening Jaw
are you pregnant?
Are you trying to become pregnant?
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