Patient Forms

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 into 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.

Medical Records Release

To Request a Medical Records Release Online:

Click HERE to complete the form and submit to Pinehurst Medical Clinic’s Medical Records Department.
*Please allow 5-7 business days for the request to be processed. Additional time may be required for mail delivery.

If you have already submitted an online request and have questions concerning your request, please contact the Medical Records Department via phone at (910) 235-3069.

To Request a Medical Records Release via Mail:

Print, complete and mail the following form: Release of Medical Information

Mail the completed Release of Medical Information Form 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 Forms

Please print, fill it out, and bring any relevant forms with you to your appointment.

Cardiology Forms 

Endocrinology Forms 

Gastroenterology Forms 

Patient Registration Form

Pulmonology and Sleep Medicine Forms 

Primary Care Forms