PERSONAL DETAILS

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Date of Birth

Which one applies to you?

I am a new patient

I am a current patient

I am agreeing to conduct this transaction by electronic means and that by checking this box I am providing my electronic signature in approval with the terms of this agreement. I understand that I am sending health information to Dr. Rishi Popat and I consent to receiving my results at the contact information entered and accept the terms and conditions.

Please wear your aligners in the photos

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If you are a Clear Aligner patient, what number aligners are you on?

Upper aligner number

Lower aligner number

How many days have you been in this aligner?

Do you have any additional information that you'd like to send Dr. Popat at this time?

LOGIN DETAILS

Please fill in the login information. Make sure to remember your password,
you will need it to access your report.

If you are already registered, please Click Here to access your account.

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Password don't match, please verify your password again.

Snap your smile

Snap a photo of your natural smile showing your teeth
like the image shown below

Please upload an image to proceed.

Attach Picture

Take a close-up pic of your smile

Snap a photo of your smile while using your fingers to pull your
cheeks to the side like the image shown below. A close-up photo
with good lighting is best.

Please upload an image to proceed.

Attach Picture

Take a pic of your Bottom Teeth

Snap a photo of your lower teeth like the image shown below. It is best to
move your tongue to the back of your mouth for best results.

Please upload an image to proceed.

Attach Picture

Take a pic of your Upper Teeth

Snap a photo of your upper teeth like the image shown below.

Please upload an image to proceed.

Attach Picture

Take a pic of your Right Bite

Snap a photo of the right side of your teeth while biting down as you
normally would like the image shown below.

Please upload an image to proceed.

Attach Picture

Take a pic of your Left Bite

Snap a photo of the left side of your teeth while biting down as you
normally would like the image shown below.

Please upload an image to proceed.

Attach Picture

Please answer the following questions:

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Are you interested in?

Braces

Aligners

Unsure

What concerns you the most about your smile or bite?

Who is your general Dentist and have you seen a dentist in the last 6 months?

Please share your mailing address, so we may welcome you to the Popat Orthodontics Family.

Whom may we thank for referring you to our office?

Comments

DENTAL INSURANCE

Popat Orthodontics is a premier in-network provider for ALL PPO insurances.
Please enter your dental insurance information below so we can verify your
orthodontic benefits (if any) prior to your complementary consultation.

Do you have Dental Insurance?

Yes

No

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Insurance Carrier / Company:

Policy Number / Subscriber ID:

Group Number:

Insurance Carrier Phone number:

Prospective Patient Date of Birth:

Policy Holder Full Name:

Policy Holder Date of Birth:

Thank You!

Thank you for completing your virtual smile analysis. Our Team at The Smile Laboratory Powered by Popat Orthodontics is looking forward to providing you more information about your smile. Your smile report will be on its way soon!

Please contact us if you have any questions.

Popat Orthodontics

602-265-0303
info@PopatOrthodontics.com