205 Durham Street South, Christchurch Central City 03 595 6686

Dr John Perry
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Patient Name:

DOB:

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Name of parent/caregiver (if under 18 years):

Orthodontic assessment required for:

Class I

Crossbite

Spacing

Class II

Deepbite

Crowding

Class III

Openbite

Impacted or missing teeth

Details:

Dentist details

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Practice Name:

Dentist Phone:

Dentist Email:

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Your consultation will be approximately 40 minutes and includes all necessary records. Dr Perry will diagnose your case and explain the treatment options. You’ll receive a quote along with payment plan options.

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