Authorization to Release Records Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Requesting records from:Dentist *Address: *Phone Number * Signature Address: x-rays Authorized to release records and x-rays to: Dr. Dean J. Kokinias 6085 Strathmoor Drive Rockford, IL 61107 Phone: 815-398-5550 Email: smiledr@kokiniasdental.com Patient Name: *Date of Birth: *Address: *CityStateZip code *Please forward current x-rays and any other pertinent information regarding patient care.Signature * Clear Signature Patient SignatureDateDateSubmit for Records
