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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