Young Consultation Form

Is Your Child In Need Of A Consultation?


Simply follow the steps:

Step 1

Fill out your child's 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 Name(Required)
DD slash MM slash YYYY
Parent/Guardian Name
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.
Max. file size: 6 MB.
Max. file size: 6 MB.
Max. file size: 6 MB.
Max. file size: 6 MB.
Max. file size: 6 MB.
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



Email Address

[email protected]