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Urgent Care, Pain Relief, Same Day Service
(843) 875-5111
Urgent Care, Pain Relief, Same Day Service
(843) 875-5111

Patient Forms

Rights of the Patient

I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to:
Summerville Dental Center • 101 Harth Place • Summerville, SC 29485.


I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward.

I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the
recipient and may no longer be protected by federal or state law.


I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
This authorization shall be in effect until revoked by the patient.

Please fill all out the forms below that apply to you. Click on the link text to download each form, type in the information required directly on the form and print them out so that you can bring them in to the office with you on your next visit. **The Patient Registration form must be printed and filled out by hand.** Thank you.