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

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 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 

• GI New 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