General Braces 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
*
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Please take and upload 10 photos of your smile like the examples above. 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
Cancel
of
Patient's Bottom
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient's Right
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient's Centre
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Patient's Left
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Photo Consent
I consent to Alpers 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
Send Information To Alpers Dental
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