Repair of Symblepharon 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: Surgical Repair of Symblepharon* Right Eye Left Eye Both Eyes I understand that adhesions may recur which could require additional surgery* Yes No Risks of the above procedure(s) include (but are not limited to) the following: Anesthetic complications including death, Infection, Recurrence of adhesions, Corneal ulceration, Corneal scarring Please Sign or Initial Below*
