There are numerous forms that need to be filled out for various purposes when you first come to the clinic. Since the enactment of HIPAA, even more paperwork is required, in order to best provide for your privacy in regard to your medical information.
We have created some of the most commonly used forms in a format that you can fill out on your computer and print, so you have the information ready when you come in to the clinic. We hope to add to this list in the future.
We’re hoping that this will improve your overall experience in coming to Pinehurst Medical Clinic. If you have a suggestion that might help us improve this service, please email us and we’ll see what we can do.
Forms currently available online are:
Follow My Health Patient Portal:
How to Create an Account
How to Make a Payment
Release of Medical Information – Print out this form, Fill it out, and
Mail it to:
Pinehurst Medical Clinic
Attn: Medical Records,
205 Page Road,
Pinehurst, NC 28374 OR Fax to:
(910)235-3413
(Please note that we use a copying service and charges may apply.)
- Patient Registration Form – Please print out this form, fill it out, and bring it with you to your appointment.
- Primary Care Health Questionnaire – Please print out this form, fill it out, and bring it with you to your appointment.
- GI New Patient Form – Please print out this form, fill it out, and bring it with you to your GI appointment.
- Endocrinology Questionnaire Form – Please print out this form, fill it out, and bring it with you to your appointment.
- Dr. Anderson/Dr. Kent Patient History Form – Please print out this form, fill it out, and bring it with you to your appointment.
- Dr. Davis/Dr. Parrish History and Risk Assessment – Please print out this form, fill it out, and bring it with you to your appointment.
- Sanford Medical Group – Authorization for Release of Medical Information
- Sanford Medical Group – New Patient Health Questionnaire
- Dr. Simpson/Dr. Hakas New Patient Form – Please print out this form, fill it out, and bring it with you to your appointment.
- Pulmonology and Sleep Medicine New Patient Questionnaire – Please print out this form, fill out and bring with you to your appointment.
- Insomnia Patient Form – Please print out this form, fill out and bring with you to your appointment.
