Patient Tracking Form: Orthodontic Plate

Patient Tracking Form: Orthodontic Plate

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. Please take photos with and without your plate on.

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 10 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 Centre(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Left(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Top With Plate On(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Bottom With Plate On(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Right With Plate On(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Centre With Plate On(Required)
Accepted file types: jpg, jpeg, png, gif.
Patient's Left With Plate On(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)

Schedule Online
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Alpers Dental

Level 3, 24 Manukau Road, Epsom,
Auckland 1023 New Zealand
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Hours

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

Phone

09-524-5056

Email Address

[email protected]