Skip to form

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


Contact Us

SeamlessDocs

03/17/2026Click to Sign
Sex
Client lives with
Title
Title_2
Had Orthodontic Treatment?1
Had Orthodontic Treatment?2
Had Orthodontic Treatment?3
Had Orthodontic Treatment?4
Does this policy have orthodontic benefits
Secondary Dental Insurance - Does this policy have orthodontic benefits?
Local Anesthetics (Novocain, Lidocaine, Xylocaine)
Cancer, Tumor, Radiation Treatment, or Chemotherapy
Kidney Problems
Primary (Baby) Teeth Removed That Were Not Loose
Latex (Gloves, Balloons)
Aspirin
Arthritis or Joint Problems
Penicillin
Acrylics
Immune System Problems
History of Osteoporosis
Hepatitis, Jaundice, or Other Liver Problems
Mental Health Disturbance or Depression
Frequent Headaches or Migraines
History of Eating Disorder (Anorexia, Bulimia)
High or Low Blood Pressure
Chipped or Injured Primary or Permanent Teeth
Any Sensitive or Sore Teeth
Angina, Arteriosclerosis, Stroke, or Heart Attack
Any Teeth Treated With Root Canals or Pulpotomies
Well-Balanced Diet
Frequent Canker Sores or Cold Sores
History of Speech Problems or Speech Therapy
Difficulty Breathing Through the Nose
Mouth Breathing Habit or Snoring at Night
)
Frequent Mouth Breathing
Teeth Causing Irritation to Lip, Cheek, or Gums
Tooth grinding or clenching
Clicking or Locking in Jaw Joints
Broken or Missing Fillings
Has your child ever had any serious trouble associated
Has your child ever been diagnosed with gum disease
Birth Defects or Hereditary Problems
Bone Fractures or Major Injuries
Any Injuries to Face, Head, or Neck
Ibuprofen (Motrin, Advil)
Endocrine or Thyroid Problems
Other Antibiotics
Diabetes or Low Sugar
Metals (Jewelry, Clothing Snaps)
Plant Pollens
Animals
Gonorrhea, Syphilis, Herpes, or Sexually Transmitted Diseases
Foods
AIDS or HIV Positive
Other Substances
Polio, Mononucleosis, Tuberculosis, or Pneumonia
Seizures, Fainting Spells, or Neurologic Problems
Erupting Teeth Very Early or Very Late
Permanent or Extra (Supernumerary) Teeth Removed
Supernumerary (Extra) or Congenitally Missing Teeth
Excessive Bleeding or Bruising, or Anemia
Chest Pain, Shortness of Breath, Tire Easily, or Swollen Ankles
Heart Defects, Heart Murmur, or Rheumatic Heart Disease
Any Lost or Broken Fillings
Jaw Fractures, Cysts, or Infections
Skin Disorder (Other Than Common Acne)
Vision, Hearing, or Speech Problems
Frequent Ear Infections, Colds, or Throat Infections
Asthma, Sinus Problems, or Hay Fever
Tonsil or Adenoid Condition
Has your child ever taken intravenous bisphosphonates
Has your child ever taken oral bisphosphonates
Soreness in Jaw Muscles or Face Muscles
TMJ or TMD Problems/Treatment
Signature HereClick to Sign
03/17/2026Click to Sign
Signature HereClick to Sign
03/17/2026Click to Sign
x

Additional Signatures Required