Client Information

Name*

First Last

Spouse

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Spouse Phone

Email Address*

Providing us with your email address will allow us to communicate with you in the event that we cannot reach you by telephone. Also, you will be able to access your pet portal through our website! There, you will be able to access your pet’s health information, access our online pharmacy, request appointments, received reminders, and more!

How did you hear about us? Who/what may we thank for referring you?*

What is your preferred method of being contacted?*

Phone call

Text

Other

Patient Information

Patient Name*

Species*

Breed*

Date of birth*

Sex*

Male

Female

Female Spayed

Male Neutered

Color*

Previous medical records can be obtained from:

Any specific medical concerns, conditions, cautions, allergies, etc?

Add a second pet?

Yes

Second Pet Information

Patient Name*

Species*

Breed*

Date of birth*

Sex*

Male

Female

Female Spayed

Male Neutered

Color*

Previous medical records can be obtained from:

Any specific medical concerns, conditions, cautions, allergies, etc?

Add a third pet?*

Yes

Third Pet Information

Patient Name*

Species*

Breed*

Date of birth*

Sex*

Male

Female

Female Spayed

Male Neutered

Color*

Previous medical records can be obtained from:

Any specific medical concerns, conditions, cautions, allergies, etc?

Add a fourth pet?*

Yes

Fourth Pet Information

Patient Name*

Species*

Breed*

Date of birth*

Sex*

Male

Female

Female Spayed

Male Neutered

Color*

Previous medical records can be obtained from:

Any specific medical concerns, conditions, cautions, allergies, etc?

Add a fifth pet?*

Yes

Fifth Pet Information

Patient Name*

Species*

Breed*

Date of birth*

Sex*

Male

Female

Female Spayed

Male Neutered

Color*

Previous medical records can be obtained from:

Any specific medical concerns, conditions, cautions, allergies, etc?

Financial Policy

Thank you for choosing Frankfort Animal Clinic. Our primary mission is to deliver the most comprehensive veterinary care available for your pet. An important part of the mission is making the cost of optimal care as easy and manageable for our clients as possible by offering several payment options such as CareCredit®. Frankfort Animal Clinic requires payment in full at the end of your pet’s examination and/or at the time of discharge.

Deposit & Billing

For some treatments or hospitalized care, a 50% deposit of estimated care may be required.

Additional Policy Information

For clients with pet insurance, we are happy to provide you with the necessary documentation to submit a claim to your insurance carrier.

If you have any questions, please do not hesitate to ask. We are here to provide the best veterinary care available for your pet.

By signing below, you agree to the foregoing terms of payment:

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