Pharmacologic Ablation of the Ciliary Body (Gentamicin Injection) for Glaucoma 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: Pharmacologic ablation of the ciliary body:* Right Eye Left Eye Both Eyes I understand that this is not a reversible procedure. There will be no possibility of vision after this has been done.* Yes No Risks of the above procedure(s) include (but are not limited to) the following: complications associated with sedation, which may include death, prolonged effects of sedation, elevation of third eyelid, corneal ulceration. Please Sign or Initial Below*
