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Records Request Form

Medical or counselling records transfer request

If you require a record transfer, please complete the form below or submit a copy of the Ìýin person at the Student Health & Wellness Centre.

 
 
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 Medical history only
 Counselling history only
 Immunizations history only
 Complete chart required (medical and counselling history)
 Specific chart item / Other (please specify in special notes below)
 
 
 
I.e., photo of drivers license or government-issued photo identification card
*
I consent to my physician, psychiatrist, psychologist, counsellor, or social worker reviewing my personal health information in order to provide it to me as requested on this form. I understand that there may be a fee to transfer my records, including any fee associated with delivery by regular mail or courier. AV¾ãÀÖ²¿ Student Health & Wellness will provide an estimate of any fees to me prior to release of my record(s), and fees will be payable by me in advance of any access.

Requirements for distribution of records

  • AV¾ãÀÖ²¿ Student Health & Wellness is required to verify an individual’s authority to access information before releasing personal health information. A clear photocopy of one piece of government issued personal identification will be required for records requests (ensure photocopy shows your photograph and your signature). This may be presented in person at time of pick up or emailed to medforms@dal.ca for forms being mailed or sent via secure message.
  • There may be a fee associated with records requests, including records transfers. The patient will be notified of the fee in advance of filling the request.Ìý
  • Records request forms will be processed within 30 days as per requirements set out in the Personal Health Information Act (PHIA).
  • If you have questions regarding your records request, please contact our Records Clerk at medforms@dal.ca.
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Need an appointment?

Online bookingÌýis available for nurses, social workers, same-day counselling and select doctors at the Student Health & Wellness Centre. Book your appointment online today.

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