Removal of Third Eyelid 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: Removal of entire nictitating membrane (third eyelid)* Right Eye Left Eye Both Eyes Risks of the above procedure(s) include (but are not limited to) the following: 1. anesthetic complications including death 2. infection 3. loss of tear production 4. corneal ulcerationI have read and understand this authorization and consent.*Please Sign or Initial Today's Date* MM slash DD slash YYYY
