Mass Removal Under General Anesthesia and Additional Cryo Caretaker Name* First Last Pet's Name* First Acknowledgement of RisksI 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:Surgical removal of:*Select OneEyelidConjunctivaBothSelect Eye:*Select OneRight EyeLeft EyeBoth EyesI want the mass(es) sent out for biopsy (If you select NO, the sample will be discarded and unable to be sent out).*Select OneYesNoI understand that the surgery may need to be repeated if there is regrowth of eyelid/conjunctival mass.*Select OneYesNoProcedural Risk AcknowledgementRisks of the above procedure(s) include (but are not limited to) the following: 1. anesthetic complications including death 2. infection 3. regrowth of eyelid mass 4. corneal ulceration 5. change in appearance of eyelid 6. surgery may need to be repeated due to regrowthI have read and understand this authorization and consent.*Please Sign or Initial Please Enter Today's Date* MM slash DD slash YYYY I have read and understand this authorization and consent.*Please Sign or Initial
