Enucleation and Dermoid Removal Form

Owner's Name*
First Last
Phone Number*
Secondary Phone Number*
Pet's Name*
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:
Dermoid Removal*
Enucleation*
I wish to have the eye(s) sent out for histopathology (If you select NO, the sample will be discarded and unable to be sent out).*
The eye will be permanently and completely removed. The eyelids will be sewn permanently shut. I understand that this is not a reversible procedure*
Your Name
Your Name
Your Name
Please Sign or Initial
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. Infection related to removal of Dermoid 6. Rupture of the cornea 7. Continued corneal ulceration 8. Corneal scarring
Today's Date*
I have read and understand this authorization and consent.*
Your Name
Your Name
Your Name
Please Sign or Initial

Please Read and Respond