Design your Smile New Patient Form

Name*
First Last
Email Address*
Contact Number*
Date of Birth*

Day
Month
Year
What are your primary concerns with your teeth?*
- Crowding
- Crooked teeth
- Shape of teeth
- Colour of teeth
- Size of teeth
Please upload your 6 photos here. PLEASE FOLLOW THE PHOTOGRAPHY INSTRUCTIONS BELOW.*
Drop files here or

Max. file size: 2 MB, Max. files: 6.

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Photo requirements

Please ensure to use your camera flash settings (an iPhone or android phone camera is fine). Do your best to match the example images below.