Patient Forms

Patient Forms

Patient Forms

A Letter of Welcome to Our Practice

Dear New Patient,

Welcome to Summerville Pediatric Dentistry. We are glad that you have chosen us to provide your child’s primary care, and we are looking forward to working with your family. 

Before your first visit, we will need you to provide us with our new patient information. We have provided a list of these forms below. This information assists the dentist and the team in providing you the best care and helps us to get to know you better! Please complete and submit each of the following documents to our office staff prior to or at the time of your first visit.

Also, please be sure to bring your insurance card(s) and required co-payment (if any) to the appointment. Once again, welcome to Summerville Pediatric Dentistry. Should you have any questions, please do not hesitate to contact us at (843)821-6433.

Warmest Regards, Dorothy Baker, DMD  Leva Sabet, DDS, Asher Wright, DDS

Patient Information Forms

To help us with your child’s chart, please download and print these forms, fill them out, and bring them to your child’s first appointment.

  1. Office Policy
  2. Financial Policy Letter to Patients
  3. Policy on Diversity, Equity and Inclusion
  4. Dentistry New Patient Forms
  5. Child New Patient Forms
  6. Adult New Patient Forms
  7. Release of Records Request Form

Schedule Your Appointment Today!