{"id":2066,"date":"2026-03-17T22:28:57","date_gmt":"2026-03-17T22:28:57","guid":{"rendered":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/?page_id=2066"},"modified":"2026-04-10T17:01:40","modified_gmt":"2026-04-10T17:01:40","slug":"authorization-to-release-records","status":"publish","type":"page","link":"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/authorization-to-release-records\/","title":{"rendered":"Authorization  to Release Records"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2066\" class=\"elementor elementor-2066\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5e99e08 e-flex e-con-boxed e-con e-parent\" data-id=\"5e99e08\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-313bf57 e-con-full e-flex e-con e-child\" data-id=\"313bf57\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-b49b11b e-con-full e-flex e-con e-child\" data-id=\"b49b11b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-876d560 elementor-widget__width-inherit elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"876d560\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Authorization to Release Records<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-853363a e-flex e-con-boxed e-con e-parent\" data-id=\"853363a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-09c0d90 authorization_form elementor-widget elementor-widget-shortcode\" data-id=\"09c0d90\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><style id=\"wpforms-css-vars-2070\">\n\t\t\t\t#wpforms-2070 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2070\"><form id=\"wpforms-form-2070\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2070\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2066\" data-token=\"14ba8cf0f39bdb8f87efb051659629a9\" data-token-time=\"1778417408\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-2070-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"1\"><h3 id=\"wpforms-2070-field_1\" aria-errormessage=\"wpforms-2070-field_1-error\">Requesting records from:<\/h3><\/div><div id=\"wpforms-2070-field_2-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"2\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_3\">Dentist <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2070-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"Enter Dentist Name\" aria-errormessage=\"wpforms-2070-field_3-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_19-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_19\">Address: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2070-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" placeholder=\"Enter Address\" aria-errormessage=\"wpforms-2070-field_19-error\" required><\/div><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-2070-field_4-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"4\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-2070-field_4\" >care. to regarding<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-2070-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-2070-field_46-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_46\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2070-field_46\" class=\"wpforms-field-large wpforms-field-required wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" data-rule-us-phone-field=\"true\" data-inputmask-inputmode=\"tel\" name=\"wpforms[fields][46]\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-2070-field_46-error\" required><\/div><div id=\"wpforms-2070-field_6-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"6\"><h3 id=\"wpforms-2070-field_6\" aria-errormessage=\"wpforms-2070-field_6-error\">Authorized to release records and x-rays to:<\/h3><\/div><div id=\"wpforms-2070-field_48-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"48\"><div id=\"wpforms-2070-field_48\" aria-errormessage=\"wpforms-2070-field_48-error\"><div class=\"doctor-info\">\r\n  <p><strong>Dr. Dean J. Kokinias<\/strong><\/p>\r\n  <p>\r\n    6085 Strathmoor Drive<br \/>\r\n    Rockford, IL 61107\r\n  <\/p>\r\n  <p>\r\n    Phone: <a href=\"tel:18153985550\">815-398-5550<\/a><br \/>\r\n    Email: <a href=\"mailto:smiledr@kokiniasdental.com\">smiledr@kokiniasdental.com<\/a>\r\n  <\/p>\r\n<\/div><\/div><\/div><div id=\"wpforms-2070-field_25-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"25\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_26-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_26\">Patient Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2070-field_26\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][26]\" placeholder=\"Enter Patient Name\" aria-errormessage=\"wpforms-2070-field_26-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_30-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_30\">Date of Birth: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2070-field_30\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][30][date]\" placeholder=\"Date of Birth:\" aria-errormessage=\"wpforms-2070-field_30-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_29-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_29\">Address: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2070-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" placeholder=\"Enter Address\" aria-errormessage=\"wpforms-2070-field_29-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_41\">City<\/label><input type=\"text\" id=\"wpforms-2070-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-2070-field_41-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_43\">State<\/label><input type=\"text\" id=\"wpforms-2070-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-2070-field_43-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_49-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-2070-field_49\">Zip code <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2070-field_49\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-2070-field_49-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2070-field_15-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"15\"><h3 id=\"wpforms-2070-field_15\" aria-errormessage=\"wpforms-2070-field_15-error\">Please forward current x-rays and any other pertinent information regarding patient care.<\/h3><\/div><div id=\"wpforms-2070-field_16-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"16\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_17-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"17\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2070-field_17\" aria-hidden=\"false\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2070-field_17\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][17]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-2070-field_17-error\" aria-describedby=\"wpforms-2070-field_17-description\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-2070-field_17-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><div id=\"wpforms-2070-field_17-description\" class=\"wpforms-field-description\">Patient Signature<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2070-field_18-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"18\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-2070-field_18\" aria-hidden=\"false\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2070-field_18\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][18][date]\" aria-errormessage=\"wpforms-2070-field_18-error\" aria-describedby=\"wpforms-2070-field_18-description\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-2070-field_18-description\" class=\"wpforms-field-description\">Date<\/div><\/div><\/div><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-2070-field_4-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-2070-field_4-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-2070-field_4-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2070\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-json\/wp\/v2\/pages\/2066\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2070\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit for Records\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit for Records<\/button><img decoding=\"async\" src=\"https:\/\/project1.1stopwebsitesolution.com\/kokiniasdental\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Authorization to Release 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