Enucleation – Surgical Consent Form

Owner's Name*

First Last

Breed*

Phone Number*

Secondary Phone Number*

Pet's Name*

Sex*

Please Read and Respond

I am the owner or agent for the owner of the above animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure:

Enucleation*

I wish to have the eye(s) sent out for biopsy.*

The eye will be permanently and completely removed. The eyelids will be sewn permanently shut. I understand that this is not a reversible procedure*

Please Sign or Initial

Has your pet ever had any seizures?*

Risks of the above procedure(s) include (but are not limited to) the following:

1. anesthetic complications including death 2. infection of orbital area 3. swelling of orbital area 4. blindness in other eye (cats primarily) 5. rejection of silicone implant

Verification of the Cost Structure

I understand that because of unforeseen circumstances, the cost of rendered services may exceed the above estimate. In this case, all charges are held as low as possible. The doctors and staff of Animal Eye Care will be glad to go over itemization and explain any charges. I understand that it may be necessary, during the procedure or hospitalization, to provide emergency medical care in the event that I cannot be contacted. Therefore, I consent to and authorize the performance of such medical or surgical interventions as are necessary and desirable in the exercise of the veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.*

Please Sign or Initial

In the unlikely event of a cardiac or respiratory arrest during hospitalization or surgery, would you like the attending doctor to perform CPR to the best of our ability with the equipment available?*

I have read and understand this authorization and consent.*

Please Sign or Initial

Enucleation – Surgical Consent Form