Patient Tracking Form: Clear Aligners

Every four weeks, we ask that you take pictures of your smile with your current aligners in, and submit those photos using the form below for the doctor to review.

Whether or not your aligners are fitting perfectly, we would like to see your progress by filling out the form below.

This page and form works well on mobile devices, so you can take the photos on your phone, and navigate to this webpage on your device to fill out the form and attach the photos directly from your phone.

Step 1

Fill out your details and upload a few photos

Step 2

Send the completed form and photos to Alpers Dental

Step 3

One of our friendly dentists will be in contact with you

Enter Your Information Below

Patient's Full Name(Required)
DD slash MM slash YYYY
Photo Upload
Please take and upload photos of your smile like the examples below. Take each photo without and with your aligners on. They must be close ups that clearly show how your teeth sit in your mouth. It's best to get a friend to take them for you.
Patient's Top(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Bottom(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Right(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Left(Required)
Accepted file types: jpg, jpeg, png, gif.
Photo Consent
I consent to Alpers uploading the following images to my confidential patient Records
Tick to Agree(Required)

Alpers Dental

Level 3, 24 Manukau Road, Epsom,
Auckland 1023 New Zealand
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Monday: 8:00 a.m. - 5:00 p.m.
Tuesday: 8:00 a.m. - 5:00 p.m.
Wednesday: 8:00 a.m. - 5:00 p.m.
Thursday: 8:00 a.m. - 5:00 p.m.
Friday: 8:00 a.m. - 4:00 p.m.
Saturday, Sunday & Public Holidays: Closed



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