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

    Dermatology Forms

    Dermatology New Patient Packets - English

    Dermatology New Patient Packets - Spanish 

    Endocrinology Forms 

    Endocrinology Questionnaire Form

      Gastroenterology Forms

      Gastroenterology Patient Form

      Patient Registration Form

      Patient Registration Form

      Pulmonology Forms 

      Pulmonology New Patient Packet - English

      Pulmonology New Patient Packet - Spanish

      Pulmonology and Sleep Medicine New Patient Questionnaire

        Primary Care Forms 

        Sanford Medical Group – New Patient Health Questionnaire

        Primary Care Health Questionnaire

        Rheumatology Forms

        Rheumatology New Patient Packet - English

        Rheumatology New Patient Packet - Spanish

        Rheumatology New Patient Health Questionnaire

        Sleep Medicine Forms

        Insomnia New Patient Packet - English

        Insomnia New Patient Packet - Spanish

        Insomnia & Obstructive Sleep Apnea Patient Form