Eyelid Reconstructive Surgery Owner Name* First Last Pet Name* First Assumption of RisksI 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: Eyelid Reconstruction:* Right Eye Left Eye Both Eyes Has your pet ever had any seizures?* yes no 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. Trichiasis (hairs rubbing on cornea) 5. Additional surgery may be necessaryPlease Sign or Initial Below*
