Glaucoma Valve Shunt Revision and Laser of Ciliary Body 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: Glaucoma Valve Shunt* Right Eye Left Eye Both Eyes Laser of Ciliary Body* 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. glaucoma - postoperative pressure spikes may occur, glaucoma can reoccur 3. infection 4. prolonged intraocular inflammation 5. retinal detachment 6. blindness 7. loss of eye I have read and understand this authorization and consent.*Please Sign or Initial Today's Date* MM slash DD slash YYYY
