Call us - (803) 932-2200

Patient Forms

General Forms

Patient Demographic Form

PDF

Notice of Privacy Practices – HIPAA

PDF

Receipt of Privacy Practice Notice – HIPAA

PDF

Authorization Form – HIPAA

PDF

Financial Policy

 PDF

Release of Medical Information

PDF

Authorization to Treat a Minor Patient in Absence of Parent or Guardian

PDF

NICHQ Vanderbilt Assessment Scale – Parent Form

PDF

NICHQ Vanderbilt Assessment Scale – Teacher Form

PDF

Authorization to have a patient’s protected medical records released to or from Chapin Pediatrics.

PDF

Edinburgh Postnatal Depression Scale

PDF

M-CHAT

PDF

Patient Health Questionnaire (PHQ-9)

PDF

Prenatal Questionnaire

PDF

Flu Season Forms

Flu InjectionClick here to download (updated: October 2013)

The above forms are in a PDF format.  If you are not able to open it, you will need to download the Adobe PDF reader to do so.  This reader can be downloaded for free by clicking here: ADOBE PDF READER

Doctor Hours

Dr. Bonnett
Monday, Tuesday, Thursday & Friday 8:00 am to 5:00 pm

Dr. Shealy
Monday, Thursday & Friday 8:00 am to 1:30 pm Wednesdays – 8:00 am to 5:00 pm

Mr. Johnson
Monday through Friday 8:00 am to 5:00 pm

Mrs. Cates

Saturday: Appointment Only (for all)

We are located at

119 Amicks Ferry Road
Chapin, SC 29036
803.932.2200
803.945.4445
Directions