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Dr. Popat Check in Form
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Client ID
Your Name
First
Last
Are you experiencing any pain or there specific concerns you would like to relay to Dr. Popat?
(Required)
Yes
No
Please note any concerns to Dr. Popat in the box below the images. Please be as specific as possible with the areas of concern.
Front Teeth Image
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Once you “Take Picture” the image will be captured after 3 seconds
Left Side Teeth Image
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Once you “Take Picture” the image will be captured after 3 seconds
Right Side Teeth Image
(Required)
Once you “Take Picture” the image will be captured after 3 seconds
Notes to Dr. Popat