To obtain a copy of your dental record, you will need to submit a completed Patient Record Request Release Form available for download by clicking on the link below. Dental records can include medical history, x-rays, case records and other sensitive information so requests must be faxed, mailed or hand delivered – e-mailing requests/records is not an option. Please allow up to 2 weeks for all request to be completed.
There is a small fee associated with processing requests that are provided directly to the patient. Record requests from dentists/dental offices are provided free of charge, so consider having your dentist or dental office handle this process.
Dentist to Dentist Requests:
There is no charge for records requests between dental offices. Please have your outside dentist complete the form below.
Direct to Patient Requests:
- A paper/electronic copy of only the patient record: $6.00
- A reproduction (CD, paper film) of a patient’s x-rays (fee also includes paper/electronic copies of the patient record & x-rays): $10.00
- A paper/electronic copy of only billing records: No Charge
You may fax your completed release form to (617) 636-6858 and call in your credit card payment to (617) 636-6986. We accept Visa, Master Card and Discover Card.
You may mail your completed release form along with your payment by check or money order to the address on the right.
You may deliver your completed form to us in person, by visiting 1 Kneeland St., Boston and speaking with a person at the front desk. Please have your check, money order, Visa, Master Card or Discover Card ready. Click here for directions.