Removal of Eyelid Mass Under General Anesthesia Form

Caretaker Name*
First Last
Pet's Name*
First
Acknowledgement 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:
Surgical removal of eyelid mass(es)*
I want the mass sent out for biopsy (If you select NO, the sample will be discarded and unable to be sent out).*
I understand that the surgery may need to be repeated if there is regrowth of the mass.*
Procedural Risk Acknowledgement
Risks 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
I have read and understand this authorization and consent.*
Your Name
Your Name
Your Name
Please Sign or Initial

Acknowledgement of Risks