Informed Consent for General Dental Procedures & Acknowledgement of Receipt of Notice of Privacy Practices

Click here to download the consent & acknowledgement form.

I authorized dental treatment including necessary or advisable examination, radiographs (x-rays), and intraoral/extraoral images. In general, dental treatment may include but is not limited to one or a number of the following:

  • Administration of local anesthesia
  • Cleaning of teeth and application of topical fluoride
  • Scaling and root planning with local anesthesia
  • Treatment of diseased or injured teeth with dental restorations.
  • The replacement of missing teeth with a dental prosthesis (crowns, bridges, partials, denture, etc.)
  • Treatment of diseased or injured oral tissues (hard and/or soft tissues)
  • Treatment of malposed (crooked) teeth and/or developmental abnormalities

*There are other dental treatments such as oral surgery, dental implant surgery, and root canal therapy that will have their own detailed consent forms.

Please fill and sign:

Notice of Privacy Practices

Authorization of PHI Disclosure (Protected Health Information):
The information described above may be disclosed to the following recipients:

By signing below, I am acknowledging that I have received a copy of TNT Dental Care's Notice of Privacy Practices. I am also giving TNT Dental Care consent to disclose my protected health information to the person(s) listed above until such time a new Acknowledgement of Receipt of Notice of Privacy Practices and Consent Form is completed by me. I also understand and agree to the terms of this authorization.

*You May Refuse to Sign This Acknowledgement*

Individual refused to sign.

Call: 617-923-0088

230 Main Street
Watertown, MA 02472

Working Hours

Mon: 8:30 am - 5:00 pm
Tue: 7:30 am - 4:00 pm
Wed: By Appointment Only
Thu: 8:30 am - 6:00 pm
Fri: By Appointment Only
Sat: By Appointment Only
Sun: Closed

TNT Dental Care
Service with a Smile!

Feel  free to contact our office with any questions you may have. We look forward to making your visit a pleasurable experience!

TNT Dental

230 Main St, Watertown, MA 02472, USA

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