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Patient Information

  • Spouse's Information

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Dental Insurance

 

Dental History

  • Place a mark on “yes” or “no” to indicate if you have had any of the following:

 

Health History

  • Place a mark on “yes” or “no” to indicate if you have had any of the following:

  • Women

 

Verification

Our office experienced severe damage during Hurricane Ida, and we are presently working out of Dr. Lya Sharpley's office in Metairie.
Our temporary address is:
4400 Trenton St, Suite J (second floor on the right)
Metairie, LA 70006
You can still reach us for appointments at our regular phone number: 985-785-0123
Thank you! - The Glaser Family Practice Team