Mooresville, NC

Dental Cleaning and Periodontal Treatment Consent Form

Please fill out the form below prior to your visit!

Owner Responsibility

  • I understand that my pet should NOT EAT after midnight the night before the procedure.
    DROP OFF TIME is between 7:30 -8:00 am on ____________________ (Date of Procedure)
  • I understand that home care administered by myself or a designated caretaker is recommended to
    achieve best overall success. It is my responsibility to notify Harbor Point Animal Hospital before
    altering the doctor’s recommendations. I understand that changes, supplementation, or alteration
    of any prescriptions may possibly result in an unfavorable or detrimental side effect with medical
  • Home care instructions will be provided at the time of my pet’s discharge
  • I agree to make myself available by telephone during the day of my pet’s anesthesia.

Hospital and Procedural Information

  • Anesthesia: Pre-surgical blood tests and physical examination will enable us to assess and
    minimize the risk of anesthesia to your pet.
  • Monitoring: To minimize anesthetic risk, we monitor the heart, blood pressure, respiration rates,
    temperature and oxygenation.
  • Catheterization: For sterility, hair will be shaved over a vein on the leg so that an intravenous
    catheter (IV) can be placed. Blood pressure may lower during anesthetic procedures and fluid
    therapy aids in supporting your pet’s internal organ systems. It also allows immediate access to
    the vascular system in case of an emergency.
  • Pain Management may be necessary in some dental procedures. The veterinarian will administer
    pain medications accordingly to your pet’s needs.
  • Antibiotics may be necessary given the degree of dental disease, and are an additional fee.
  • Radiographs: All dental procedures include full mouth radiographs. Much of the teeth lie below
    the gum line and radiographs are necessary to determine periodontal health.


It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infections for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require an extraction or referral to a veterinary dentist for repair. The cost of extractions varies depending on the difficulty and can range from $36 to $240 per tooth. The veterinarian WILL call if there are severely diseased teeth.


I have read and fully understand this dental consent form.

I authorize anesthesia and dentistry for my pet, as described above. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia, dentistry, and/or surgery, and I am encouraged to discuss any concerns I have about those risks with the hospital’s medical staff before the procedure is initiated. Additionally, I authorize Harbor Point Animal Hospital to perform any diagnostic or medical treatment as deemed necessary for any unforeseen medical or surgical complications if one should arise. While Harbor Point Animal Hospital provides the highest quality of anesthetic monitoring, dentistry, and surgical services, I completely understand the possibility of unforeseen complications that may occur during any associated anesthetic, dentistry, or surgical procedure. I fully acknowledge and understand these medical risks. I recognize that the veterinarians and hospital staff will do all that is necessary to minimize such risks. I will hold harmless Harbor Point Animal Hospital, the veterinarians, or any hospital staff member liable for any complications that may or should arise in my pet’s medical treatment and care. I understand that the hospital is not liable for any lost or damaged personal property (leashes, collars, etc) that are left in the hospital.

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