Patient Tracking Form: General Braces

Take pictures of your smile and submit those photos using the form below for the doctor to review when required.

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)

First Last

Patient's Birthday(Required)

Email(Required)

Phone(Required)

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.