Surgical Repair of Scrolled Cartilage of the Third Eyelid Form

Owner Name*
First Last
Pet Name*
First
Assumption 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 authorize the repair of a scrolled cartilage of the third eyelid of the right/left/both eye(s). I understand that the third eyelid may still not stand up straight after this procedure.
Has your pet ever had any seizures?*
- Yes
- No
I hereby consent to this procedure on the:*
- 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. refolding of the third eyelid cartilage 4. corneal ulceration
Today's Date*
Please Sign or Initial Below*
Your Name
Your Name
Your Name

Assumption of Risks