Call us - (803) 932-2200

Patient Forms

General Forms

Patient Demographic Form

PDF (updated: 2018 September)

Notice of Privacy Practices – HIPAA

PDF (updated: 2018 September)

Receipt of Privacy Practice Notice – HIPAA

PDF (updated: 2018 September)

Authorization Form – HIPAA

PDF (updated: 2018 September)

Financial Policy

PDF (updated: 2018 September)

Release of Medical Information

PDF (updated: 2018 September)

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

PDF (updated: 2018 September)

NICHQ Vanderbilt Assessment Scale – Parent Form

PDF

NICHQ Vanderbilt Assessment Scale – Teacher Form

PDF

Records Request-Release

PDF (updated: 2018 September)

Edinburgh Postnatal Depression Scale

PDF

M-CHAT

PDF

Patient Health Questionnaire (PHQ-9)

PDF

Prenatal Questionnaire

PDF

Flu Season Forms

Flu Injection Click here to download (updated: 2018 September)

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, Tuesday & Thursday
8:00 am to 1:30 pm
Wednesdays – 8:00 am to 5:00 pm

Dr. Bolen
Monday, Wednesday, Thursday & Friday
8:00 am to 5:00 pm

Mrs. Edwards
Tuesday, Wednesday & Thursday
8:00 am to 5:00 pm

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

Saturday: Appointment Only (for all)

We are located at

723 Chapin Road
Chapin, SC 29036
803.932.2200
803.945.4445
Directions