Welcome to Rankin Animal Clinic 
                                          601-939-3028
    Please take a few moments to complete this information form about you and your pet(s).
        Please tell us up front if you cannot render full payment.   Date:_______________

    Pet Owner's Information: (About Yourself)
    Name________________________________________________Spouse___________________________
    Street Address:______________________________________________________________________
    City:____________________________________________State:___________Zip:_______________
    Telephone Numbers: Home___________________________Work_______________________________
                       Cell Phone_______________________Pager____________________________
    Place of Employment__________________________________________________________________
    SSN(Required)_______________________________Spouse SSN_______________________________
    Driver's License Number______________________________________________________________
    Do you want us to keep treatments to a minimum for financial reasons?________________
    Payment Preference: Cash___________Check________________Bank/Credit Card_____________
    Who may we thank for referring you to our Clinic?____________________________________

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    Your Pet's Information:                        Enter 2nd Pet's Information:
    Pet's Name___________________________________  Pet's Name____________________________
    Dog, Cat, or Other____________________         Dog, Cat, or Other____________________
    Breed_________________________________         Breed_________________________________
    Sex:________Spayed or Neutered?_______         Sex:_______Spayed or Neutered?________
    Date of Birth___________Age___________         Date of Birth_____________Age_________
    Color/Description_________________________     Color/Description_____________________
    Date/Place of previous vaccinations (shots):
    Pet No. 1:____________________________________ Pet No. 2:____________________________
    ______________________________________________ ______________________________________
    Is your pet on Heartworm Preventative? If so, what kind?
    Pet No. 1:____________________________________ Pet No. 2:____________________________
    ______________________________________________ ______________________________________
    Reason for today's visit:
    Pet No. 1:____________________________________ Pet No. 2:____________________________
    ______________________________________________ ______________________________________
    If your pet is getting surgery today, would you like pre-anesthesia testing?
    Pet No. 1:____________________________________ Pet No. 2:____________________________
 
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    Please read and sign the agreement below:

    I hereby consent and authorize your clinic and veterinarians, Dr. Scott M. Leber,
    Dr. Kristin Berry, or other doctors on staff, to receive, prescribe for, treat, or
    operate upon my pet(s). You are to use all reasonable precautions against injury,
    escape, or destruction of the animal(s), but you will not be held liable or responsible
    in any manner whatever, or any circumstances, on account of the care, treatment or
    safe keeping of the animal(s) above described, or otherwise in connection therewith,
    as it is thoroughly understood that I assume all risks. I also understand that entire
    financial responsibility is due at time of discharge, and I take full responsibility
    for all fees incurred. I also understand that second parties are not responsible for
    fees incurred. I have read the foregoing and agree.

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       Signature of Owner                                        Date