Virtual Consultation Registration Form

1
Unique ID
2
Full Name* This field is required.
First Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.
Area Code (+27) ZA
Phone Number
5
E-mail
patient@brightsmile.co.za
6
Date of birth
Date
Year
Month
Day
7
How did you hear about us?* This field is required.
Please Select
Please Select
Received a link from my dentist
A friend
Social media
Online advertisement
Google
Please choose an option
8
Are you experiencing any dental pain* This field is required.
YESNO
9
What is the primary goal for treatment
Straighten teeth, cleaning, tooth ache, etc.
10
Patient consentI understand that this virtual consultation is not a physical consultation or treatment, and my submission is primarily used to provide photographic information to improve communication between me and the dental practice involved. I hereby grant permission to the dental practice, to capture my personal information, and contact me with possible treatment suggestions or offers.
Yes
11
Front viewTake an image directly from the front Use your index and middle finger of both hands to retract cheeks and lips. Ask someone to help take the photo or use a mirror or the timer function Example image
12
Upload your files hereFront View
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
13
Right viewTake an image from the right side Use your index and middle finger to retract cheeks and lips. Ask someone to help take the photo or use a mirror or the timer function Example image
14
Upload your files hereRight View
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
15
Left viewTake an image from the left side Use your index and middle finger to retract cheeks and lips. Ask someone to help take the photo or use a mirror or the timer function Example image
16
Upload your files hereLeft View
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
17
Upper viewTake an image from the upper arch Open as wide as you can to show as much of the teeth as possible Ask someone to help take the photo or use a mirror or the timer function Example image
18
Upload your files hereUpper View
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
19
Lower viewTake an image from the lower arch Open as wide as you can to show as much of the teeth as possible Use your index fingers where necessary to retract the lips Ask someone to help take the photo or use a mirror or the timer function Example image
20
Upload your files hereLower View
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
21
AppointmentIf you want to see if a possible appointment time-slot is available, please select
Should be Empty: