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:

Date

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.

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