Patient Forms

Medical Records Release Form

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 

• Dr. Anderson/Dr. Kent Patient History Form
  
• Dr. Davis History and Risk Assessment  
• Dr. Simpson/Dr. Hakas New Patient Form

Endocrinology Forms 

• Endocrinology Questionnaire Form

Gastroenterology Forms

• Gastroenterology Patient Form

Patient Registration Form

• Patient Registration Form

Pulmonology and Sleep Medicine Forms 

• Pulmonology and Sleep Medicine New Patient Questionnaire
• Insomnia Patient Form

Primary Care Forms 

• Sanford Medical Group – New Patient Health Questionnaire
• Primary Care Health Questionnaire