Records & Forms

Central Records

  • Room B390, 1011 N. University Ave, Ann Arbor, MI 48109-1078
  • For record duplication:  734-764-6152
  • Fax: 734-615-7040

If you would like a copy of your records, we require a release form.  You will need to download the form below.   Print, complete and return by fax, mail or in person to Central Records.  Please allow a period of two business days to process and complete your request.

 

Sending radiographic documents to Patient Services

  • X-Rays can be sent via email to: Dentalrecordcopy@umich.edu
  • Include patient name, date of birth, referring provider name or clinic and image capture date

Forms

The following forms should be printed and completed by you prior to your appointment to bring with you.

If you are accompanied by a family member or friend and would like that person to be involved in discussing your care, please print, complete and return this form at your next appointment.

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