Request for clinical records

Patient DOB:

Dear TwentyOneDental

Please could you arrange for:
my xrays/scans onlya full copy of my clinical notes and xrays/scansdigital clinical models/laboratory workI am moving to another dentistI need to send my clinical records to my insurance companyI would like them for my recordsI would like my account with TwentyOneDental to be made inactive

to be transferred to the following recipient at your earliest convenience. I confirm that I am the patient named above (or the parent or guardian responsible for the child named above).

I consent for the requested clinical data kept by TwentyOneDental for the above named patient to be sent to the designated recipient below. I understand that data legislation allows up to 30 days to process this request. However, TwentyOneDental aim to provide this information within 2 weeks.

For any physical clinical models or physical laboratory work. I understand a charge will be payable by me.

All digital files will be forwarded to this email address via our secure email link.

Please add any additional email to which you would like your data to be copied too when transferring via our secure email link.

I understand that previous work carried out at TwentyOneDental is covered by guarantees up until my date of departure from TwentyOneDental.

I understand that TwentyOneDental guarantees will no longer apply to work carried out after I have left the practice and I am under the care of another dental surgeon.

For any physical clinical models or physical laboratory work, I understand a charge will be payable by me.

I understand and agree that TwentyOneDental takes no further responsibility for my dental health after my request for transfer to my new dental provider from the date given below.

Transfer Request Date*:

Δ