Polidocanol Injection 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: Polidocanol Injection* Right Eye Left Eye Both Eyes I understand that complete sclerosing of fluid secreting tissue may not occur which could require additional surgery* Yes No Risks of the above procedure(s) include (but are not limited to) the following: Sedation complications including death, Prolonged effects of sedation, Infection, Incomplete sclerosing of fluid secreting tissue, Elevation of third eyelid, Corneal ulcerationPlease Sign or Initial Below*
