- 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 and a small processing fee. You will need to download the two-page form below. Print, complete and return with payment by fax, mail or in person to Central Records.
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
The following forms can 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
- Consent Form - Minors
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.