Cryosurgery for Treatment of Ectopic Cilia and Distichiasis Caretaker Name* First Last Pet's Name* First Acknowledgement of RisksI 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:Cryosurgery for removal of Ectopic Cilia*Select OneRight EyeLeft EyeBoth EyesCryosurgery for removal of Distichia*Select OneRight EyeLeft EyeBoth EyesHas your pet ever had any seizures?* Yes No Procedural Risk AcknowledgementRisks of the above procedure(s) include (but are not limited to) the following: 1. anesthetic complications including death 2. infection 3. corneal ulceration 4. loss of eyelid pigment 5. the eyelids will be very swollen for 1-2 weeks 6. In young animals, new lashes or some regrowth of old lashes may occur necessitating repeat surgery.Please Enter Today's Date* MM slash DD slash YYYY I have read and understand this authorization and consent.*Please Sign or Initial
