Please note: We will be closed on Monday, May 26th, in observance of Memorial Day

Canine Check-In Form

Thank you for giving us the opportunity to care for your pet! We’ll be happy to answer any questions you have about your pet’s health. To ensure the best care possible, please take the time to fill in this form completely.

Date(Required)

Month

Day

Year

Owner Name(Required)

First Last

Email(Required)

What phone number should we use to contact you?(Required)

I consent to receive SMS text messages from Fillmore Animal Hospital. Msg & data rates may apply. Reply STOP to opt out.(Required)

I Agree

Patient Information

Patient's Name(Required)

Patient's Age(Required)

How long have you owned the patient?(Required)

Who is your insurance provider, if any?(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Sex(Required)

Male

Female

Neutered Male

Spayed Female

New Client(Required)

Yes

New Patient(Required)

Yes

Is your dog(Required)

Indoor

Outdoor

Both

Patient Check-In

When was your dog's last exam?(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

What was the reason for their visit?(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

What doctor did you see?(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Vaccination History

Please list the dates your cat last received the following vaccines. If Not Applicable, please write "Not Applicable" or "N/A" or if unknown please write "Unknown"

Rabies(Required)

DA2PP(Required)

Bordetella(Required)

Lab History

Please list the dates of your cat's previous labwork. If Not Applicable, please write "Not Applicable" or "N/A" or if unknown please write "Unknown"

Routine Bloodwork(Required)

Heartworm Test(Required)

Fecal Exam(Required)

Thyroid Panel(Required)

Dental

Date of last dental procedure(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Patient History

Reason for Visit(Required)

Date symptoms started(Required)

Month

Day

Year

Current food and amount given(Required)

Treats/”People Food”/etc(Required)

Current Medications and/or Supplements(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Flea and/or Tick Preventative(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Last Given(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Heartworm Preventative(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Last Given(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Microchipped?(Required)

Yes

If no, would you like a microchip?(Required)

Yes

Previous Vet (if not here)(Required)

If Not Applicable, please write "Not Applicable" or "N/A"

Please Check All That Apply(Required)

Vomiting

Diarrhea

Appetite Changes

Water Intake Changes

Urination Changes

Bowel Movement Changes

Lethargy

Stiffness/Pain

Limping

Coughing

Sneezing

Nasal discharge

Scratching ears

Shaking head

Odor in ears

Shaking Head

Itchy/Scratching

Licking

Growths or Tumors

Scooting/Bothering Rear

Increased Panting

Anxious

Excessive Vocalizing

Hiding

None

Other

If other, please explain(Required)

If appetite changes, please describe

Easting more

Eating Less

If water intake changes, please describe

Drinking more

Drinking Less

Energy Level

Tire easily

Lethargic

Normal

Active

Behavior

Aggression

Fear

Anxiety

Urination

Increase

Decrease

Normal

Lameness

Limping

Painful

Decreased range of motion

Change in gait

Defecation

Hard Stool

Soft Stool

Diarrhea

Increased Frequency

Decreased Frequency

Scooting

What other concerns do you have? What brings you in today?(Required)

Any Additional Notes

CAPTCHA

This field is for validation purposes and should be left unchanged.

We’re pleased to provide Exceptional Pet Care in Fillmore, CA!

At Fillmore Animal Hospital, we treat you and your pets like our family. Our team is dedicated to providing the best care possible for the pets of Fillmore, Santa Paula, Piru, Santa Clarita, Moorpark, Saticoy, and Ventura.

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Contact Info

Phone: 805-524-2661
Email: frontdesk@fillmoreanimalhospital.com

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Location

557 Santa Clara St.
Fillmore, CA 93015

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Hours

Mon, Tues, and Thurs: 8:00am - 5:30pm
Wed: 8:30am - 5:00pm
Fri, Sat, and Sun: 8:30am - 1:45pm

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Vaccine Clinic Hours

Current Patients Walk-in Vaccine Hours
(for new patients call for an appointment)
AM: Monday & Thursdays:
Hours: To be Determined
PM: Monday & Thursdays
Hours: To be Determined
Wednesdays:
Hours: To be Determined

Have a question?

Complete the form below and we’ll be in touch with you shortly.

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