• Release of Information

  • Format: (000) 000-0000.

  • I hereby authorize the release of all dental information to Dr. Yi Jin's dental office.

    Please provide the following details:

  • 1. Date of last recall:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 2. Date of last scaling:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 3. Date of last complete oral exam:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 4. Date of last bitewing radiographs:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 5. Date of last panoramic radiograph:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please forward all radiographs taken within the last 24 months.

    Please provide the previous dental treatment records (restoration, root canal, extraction, etc.) and the date of completion in your office for the patient within the last 10 years. Please also include the last periodontal records if available.

    Thank you in advance for your assistance in making this a smooth transition for the patient. Your cooperation with this request is greatly appreciated.

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: