Maile S.C. Kim DDS, Bren M. Chun DDS

642 Ulukahiki St., Suite 308 Kailua, Hawaii 96734-4439

808-261-5354

Dental Records Release Form

PATIENT INFORMATION:

I hereby authorize Kim Pediatric Dentistry Inc. to release information from the dental records of the following patient(s):

Patient Name

'

Date of Birth

Patient Name

Date of Birth

Phone:
Email:

I am requesting information for:

to

Information to be released (please select all applicable):

Purpose of release:

Please release information to:

- OR -

Name:
Address:
City/State:
Zip:
Phone:
Fax:
E-mail:
Name:
Address:
City/State:
Zip:
Phone:
Fax:
E-mail:

Method of delivery:

AUTHORIZATION

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.

Signature

Use your mouse cursor or the tip of your finger to sign below

Date:
Relationship:

© 2022 - American Dental Software All rights reserved.