Removal of Eyelid Mass Under General Anesthesia Caretaker Name* First Last Pet's Name* First Acknowledgement 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:Surgical removal of eyelid mass(es)*Select OneRight EyeLeft EyeBoth EyesI want the mass sent out for biopsy (If you select NO, the sample will be discarded and unable to be sent out).*Select OneYesNoI understand that the surgery may need to be repeated if there is regrowth of the mass.*Select OneYesNoProcedural Risk AcknowledgementRisks 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 eyelidI have read and understand this authorization and consent.*Please Sign or Initial Please Enter Today's Date* MM slash DD slash YYYY I have read and understand this authorization and consent.*Please Sign or Initial
