Dermoid Removal/Cryosurgery for Removal of Ectopic Cilia Owner Name* First Last Pet Name* First Assumption of Risks - Dermoid RemovalI am the owner or agent of the above animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure: Dermoid Removal* Right Eye Left Eye Both Eyes Risks of the above procedure(s) include (but are not limited to) the following: anesthetic complications including death, infection, rupture of the cornea, continued corneal ulceration, corneal scarring. Assumption of Risks - Cryosurgery for Removal of Ectopic CiliaI am the owner or agent 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* Right Eye Left Eye Both Eyes Risks 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 Please Sign or Initial Below*
