Placement of Third Eyelid Flap(s) Owner's Name* First Last Pet's Name* Assumption 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: Placement of third eyelid flap(s)* Right Eye Left Eye Both Eyes I understand that the third eyelid flap(s) may fail which could require additional surgery*Please Sign or Initial Risks of the above procedure(s) include (but are not limited to) the following: anesthetic complications including death, prolonged recovery from anesthesia infection, failure of third eyelid flap, corneal ulceration*Please Sign or Initial
