Eyelid Tacking Sutures/Staples Form

Owner's Name*
First Last
Pet's Name*
Assumption of Risks
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:
Eyelid tacking sutures/staples*
- Right Eye
- Left Eye
- Both Eyes
Procedural Risk Acknowledgement Risks of the above procedure(s) include (but are not limited to) the following: 1. anesthetic complications including death 2. infection 3. corneal ulceration
Today's Date*
I have read and understand this authorization and consent.*
Your Name
Your Name
Your Name
Please Sign or Initial

Assumption of Risks