Client Information 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.  Existing clients should also fill out this form if any pertinent information has changed.

Welcome to Fillmore Animal Hospital! Be assured that the health of your pet is our highest concern and we will do everything possible to maintain that health. This document is legally binding and by signing below you are certifying that you are at least 18 years old, that you are legally capable of entering into a legal agreement and that you have the legal authority to authorize our facility to provide veterinary care, boarding services and grooming services to any pet(s) registered with us in your name.

Your signature below also confirms that you completely understand that all medical, surgical and anesthetic procedures carry some inherent risk, up to and including death of your pet(s). You understand that there are no guarantees, neither stated nor implied, of the outcome or the result of veterinary services or products. It is thoroughly understood that you assume all risk and that you will not hold Fillmore Animal Hospital, its doctors, its staff or its agents responsible for the outcome of any services, procedures and product usage.

You understand that you assume full financial obligations for services and products we provide to you and your pet(s). Payment is due in full at the time services are performed. We do not accept payment plans and we do not bill. If you require an estimate of fees, you are expected to ask for one prior to the onset of the service(s). We accept cash, Visa, MasterCard, Discover and American Express. We also offer Care Credit and ScratchPay to those who qualify. We do not accept personal checks at this time.

See our privacy policy for more information.

● We make every attempt to see your pet at your scheduled appointment time however the unpredictability of pet emergencies can sometimes disrupt our normal schedule. We thank you in advance for your patience and understanding if you are not seen on time.

● Our hospital utilizes video and audio recordings to assist in serving you. California is a two way consent state for video and audio recordings and this serves as consent to participating. If you have any questions about what we utilize we are happy to answer them.

● We often take pictures of our patients to share with our FAH client family on Facebook and Instagram. We love all our patients and we know you all love seeing them online!

● Our hospital is not staffed 24-hrs a day and therefore, we cannot provide continuous after-hours medical care. Sick and injured animals requiring constant overnight care may be sent, at the sole discretion of Fillmore Animal Hospital, to VSEC in Thousand Oaks, or another 24-hr care facility, at the owner’s expense.

● We do not provide regular after-hours emergency service. If you have an after-hours emergency, please contact VSEC at (805) 492-2436.

● Our veterinarian may occasionally be unavailable during our regular business hours. During these times our office is still open and able to take care of any non-medical services, to refill medications and pet food and to schedule appointments.

● If you have a pet urgent need during regular hours, please call us as soon as possible, to see if we have availability and let us know you are coming. Emergency patients are seen by the veterinarian in as timely of a manner as possible.

● Information collected on this form is used for patient medical-related purposes, either directly through our office or through our business associates that we have contracted with to perform certain services. These services may include, but are not limited to, appointment reminders, billing and collections, satisfaction surveys, laboratory services, medical record preparation and consultation services.

● Rabies vaccinations administered are reported to the Ventura County Animal Services for licensing purposes. We have no choice in this matter.

Clear Signature