Aligner Tracking
ENTER THE PATIENT CONTACT INFORMATION
Patient's full name
*
First Name
Last Name
Patient's birth date
*
-
Day
-
Month
Year
Date
Email address
*
example@example.com
Phone number
*
Aligner number are you currently on?
*
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Please take and upload 4 photos of your smile like the examples above. 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
*
Browse Files
Drag and drop files here
Choose a file
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of
Patient's Bottom
*
Browse Files
Drag and drop files here
Choose a file
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of
Patient's Right
*
Browse Files
Drag and drop files here
Choose a file
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of
Patient's Left
*
Browse Files
Drag and drop files here
Choose a file
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of
Photo Consent
I consent to Alpers Dental uploading the following images to my confidential Patient Records.
Tick To Agree
*
Yes
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Please write any questions / notes that you have
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