Sequestrum Removal with or without Conjunctival Graft or Corneoscleral Transposition 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: Sequestrum Removal* Right Eye Left Eye Both Eyes With Graft: (Select One)* Conjunctival Flap (Graft) Corneoscleral Transposition Risks of the above procedure(s) include (but are not limited to) the following: anesthetic complications including death, infection, prolonged intraocular inflammation, continued corneal ulceration, corneal scarring (a scar, larger than the size of the defect that is gray or pink in color will occur and be permanent), breakdown of conjunctival or corneal graft tissue due to infection or scarring may necessitate reoperation, loss of eye, rupture of eye, recurrence of sequestrum.Please Sign or Initial Below*
