Laser Retinopexy 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: Laser Retinopexy:* Right Eye Left Eye Both Eyes Risks of the above procedure(s) include (but are not limited to) the following: anesthetic complications including death, preventive laser retinopexy reduces but does not eliminate the possibility of retinal detachment from occurring. Barrier laser estimated 65-75% chance prevents progression of retinal detachment, failure and blindness if retinal detachment occurs and/or progresses to involve the entire retina, infection, glaucoma, prolonged intraocular inflammation, corneal ulceration, loss of eye. Please Sign or Initial Below*