Phacoemulsification for Cataract Removal Form

Owner's Name*
First Last
Pet's Name*
First
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:
Phacoemulsification for Cataract Removal*
- Right Eye
- Left Eye
- Both Eyes
In some cases, it will be possible to insert an artificial lens to improve vision. The dog will be able to see without this lens, but vision will be better with it. This cannot be done in all cases. The decision will be made during the surgical procedure.
Risks of the above procedure(s) include (but are not limited to) the following: anesthetic complications including death, infection, glaucoma, prolonged intraocular inflammation, corneal ulceration, retinal detachment, blindness, and/or loss of eye.
Please Sign or Initial Below*
Your Name
Your Name
Your Name

Assumption of Risks