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Dental Consent Add-On

*This form is to be used in conjunction with the Anesthesia/Surgery Consent Form. If your pet is in need of a dental cleaning, please fill out both.*

I, hereby consent and authorize Southlake Crossing Animal Clinic, it's doctors and technicians to perform a dental cleaning and polishing on my pet. In, addition, a complete oral and dental examination will be performed as part of the dental procedure. The health of the teeth and degree of periodontal disease is often best assessed when the pet is under anesthesia. At that time, diseased or fractured teeth are often found that may require medical attention and often extraction. Occasionally, ares where teeth are extracted require suturing in order to aid the healing process. The following explains some procedures and treatments which may be encountered or chosen.

Extractions- Costs vary depending on tooth and quantity

Occasionally a tooth may be chipped, cracked, or damaged from periodontal disease. These teeth must be removed to stop pain, inflammation and infection. We use diagnostic tools such as digital x ray and our best medical judgment when it comes to determining whether a tooth can remain or needs to be extracted. Extraction costs vary depending on which tooth is involved, suturing, etc. Antibiotics are sometimes prescribed following tooth extraction.

Please check one of the following.

Periodontal Pocket Treatment

Periodontal disease can lead to deep periodontal recesses or pockets between the gum and the tooth. If the tooth is still healthy and anchored to the underlying bone, a hardening antibiotic gel can be injected into the pocket to allow healing to occur between the gum and the tooth, thus saving the tooth.


Ora-Vet is a product designed to slow down the buildup of tartar on your pet's teeth. It is a protective coating that is applied immediately following the dental cleaning. There is also a follow-up product to use at home starting two weeks after the initial application and once a week every week thereafter.

By signing this document you agree to the terms listed above.