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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 Medical or Counselling Records Transfer Request Form in person at the Student Health & Wellness Centre.

 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

Requirements for distribution of records

  • Dalhousie 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 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. 
  • 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