- 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
Are you a guardian for a patient? You must bring documents with you to prove that.
The following forms should be printed and completed by you prior to your appointment to bring with you.
- Registration Form
- Health History Form
- Consent Form - (read only) Electronic signature required at registration
- Temporary Consent Form for Adults with a Guardian and Minors - Are you bringing someone who has a guardian that is not available for the appointment? Ask the guardian to complete this information so you can bring it to the patient's appointment.
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.