Kim Pediatric Dentistry
Maile S.C. Kim DDS, Bren M. Chun DDS 642 Ulukahiki St., Suite 308 Kailua, Hawaii 96734-4439 808-261-5354
Maile S.C. Kim DDS, Bren M. Chun DDS
642 Ulukahiki St., Suite 308 Kailua, Hawaii 96734-4439
808-261-5354
I hereby authorize Kim Pediatric Dentistry Inc. to release information from the dental records of the following patient(s):
to
- OR -
I acknowledge that the above requested records will NOT be released until any existing balance has been cleared from my family’s account.
I understand that this entire form must be completed before any records can be released.
I acknowledge that this authorization is valid for a period of 6 months or until expressly revoked by me. I understand that I may withdraw this authorization by submitting a written, dated request, and that such revocation does not affect action that has already been taken based on this authorization.
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