E-Consultation
Twenty One dental clinic dentist New Church Road Brighton Hove

Request for clinical records

Please use the form below to request a copy of your clinical records at TwentyOneDental

Patient Clinical Request

Please complete this form if you would like TwentyOneDental to send a copy of your xrays/scans to a third party and/or yourself or would like to see what data we hold for you. A copy of your xrays/scans and/or all clinical data we hold for you will be sent via a secure link to the email address you have requested below. Any physical models/laboratory work can be posted by recorded delivery upon request for a nominal covering charge or collected from the practice by the patient. Each patient over the age of 16 should complete a separate copy of this form. Parents or guardians should complete a separate copy of the form for each child under the age of 16 under their care. Please note that it is not permissible for us to delete clinical data held for patients attending our clinic in line with our obligations to maintaining GDC Standards for the Dental Team – Standard 4.1. (See https://www.gdc-uk.org/information-standards-guidance/standards-and-guidance/standards-for-the-dental-team/).

Dr Adyl M Asani BDS BSc (Hons) London
Dental & Implant Surgeon | Clinical Director

wentyOneDental Patient notes transfer request

    Patient DOB:

    Dar TwentyOneDental

    Please could you arrange for:

    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*:

    I’d like to be informed of exclusive offers and other practice information Yes

    *By Clicking ‘Send’ You Are Consenting To Us Replying, And Storing Your Details. (see our privacy policy).

    We look forward to welcoming you into our friendly clinic
    book online

    Address

    We are situated to the West of Hove Museum (on the corner of New Church Road and Pembroke Gardens) TwentyOneDental, Digital Dentistry & Implant Clinic 21 New Church Road Brighton & Hove BN3 4AD

    Phone

    01273 202 102

    Whatsapp

    07495510965

    Email

    hello@twentyonedental.co.uk

    Opening Hours

    Monday
    8:00am - 8:00pm
    Tuesday
    8:00am - 8:00pm
    Wednesday
    8:00am - 8:00pm
    Thursday
    8:00am - 8:00pm
    Friday
    8:00am - 8:00pm
    Saturday
    By appointment only