Referrals and Dental Records
Please download the appropriate form to refer patients for specialty treatment:
- Endodontics (PDF)
- Oral Medicine (English .doc) | Oral Medicine (Spanish .docx)
- Oral Surgery (PDF)
- Postgraduate Periodontics (PDF) / Periodontics Faculty Prac (PDF)
- Pediatric (PDF)
For all other specialties, click here to contact the department directly.
|Endodontics (Root Canal)
|Faculty Dental Practice
|Oral Medicine Clinic
|Oral Surgery (Extractions)
|Pediatrics (Children 14 and Under)
|Periodontics (Gum Disease, Implants, and Gum Disorder)
|Prosthodontics (Dentures, Implants & Partials)
|Implant and Innovations Center
In order to receive copies of your dental records, please complete and sign a valid Authorization To Release Health Information Form (PDF). You can either download the form from the link below or obtain it by contacting the Records and Registration Department at 312.355.1984 (Hours of Operation: 8:00 am-4:00 pm, Monday-Friday).
Once the form is completed and signed, it should be returned to the Office of Registration and Records either in person during business hours at 801 S. Paulina Room 103 Chicago, IL 60612 or via fax at 312.413.0947. Please allow 14 business days for processing.
Authorization To Release Health Information Form (English): Download (PDF)
Please note: Processing fees, as defined by Illinois State Laws, may apply. If you are not requesting specific documentation, you will be provided with an abstract which usually includes all electronic treatment notes, x-rays and signed consents.