7/29/2019 NewClient FillmoreAnimalHospital

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Charles E. Lidikay, D.V.M.

We Treat You and Your Pet Like Family

Client RegistrationThank you for giving us the opportunity to care for your pet. Well be happy to answer any questions you have about your pets health. To insure the best care

possible, please take the time to fill in this form completely. Thank you!!!

Owner Name Email Address

Spouse/ Co-owner Name Home Telephone May We Leave Messages on this line?

YesNo

Street Address Mobile Telephone May We Leave Messages on this line?

YesNo

City, State Zip Work Telephone May We Leave Messages on this line?

YesNo

Drivers License Number Home Telephone May We Leave Messages on this line?

How did you hear about our hospital? 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 Veterinary Medical and Surgical Group (VMSG) in

Ventura, or another 24-hr care facility at the owners expense.

We do not provide regular after-hours emergency service. If you have an

after-hours emergency, you will need to contact VMSG at (805) 339-2290.

Pets may occasionally be seen after-hours if we are able. You can reach

the veterinarian by cell phone at (805) 223-5996. Leave a voicemail if he is

unable to answer your call.

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 emergency during regular hours, please call us as soon

as possible, to let us know you are coming. Doing so may allow us time to

prepare for your arrival. Emergency patients are seen by the veterinarian

in as timely of a manner as possible.

Internet Yellow Pages Drive By

Referral from a friend or family member

If so, who may w e thank ?How many pets do you own?

Previous Veterinarian Information (if applicable):

Office Hours Monday, Wednesday and Friday 8 am to 5:30 pm

Tuesday and Thursday 8 am to 7 pm

Closed on Saturday and Sunday

Appointments are preferred, however walk-ins are welcome.

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 patienceand understanding if you are not seen on time.

We would like your experience with us to exceed your expectations. Do you have any concerns or needs that we can help you with?

Welcome to Fillmore Animal Hospital - Be assured that the health of your pet is our highest concern and we will do everything possibl

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

legally capable of entering into a legal agreement and that you have the legal authority to authorize our facility to provide veterinary c

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 inhe

risk, up to and including death of your pet(s). You understand that there are no guarantees, neither stated nor implied, of the outcome orresult of veterinary services or products. It is thoroughly understood that you assume all risk and that you will not hold Fillmore Anim

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

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 expecte

ask for one prior to the onset of the service(s). We accept cash, Visa, Mastercard, Discover and American Express. We also offer Care Cr

to those who qualify. We do not accept personal checks at this time.

Your signature below indicates that you have reviewed and agree to all of the above policies and that the information given by you is tru

best of your knowledge.

Signature_______________________________________________________ Date______________________________Information collected on this form is used for patient medical-related purposes, either directly through our office or our through our business associates that we have contracted with to perfo

certain services. These services may include, but are not limited to, appointment reminders, billing and collections, satisfaction surveys, laboratory services, and consultation services.

M W F 8 am 5:30 pm

T Th 8 am 7 pm

Telephone (805) 524-2661

557 Santa Clara St

Fillmore, Ca 93015

www.FillmoreAnimalHos ital.com

Please Print and Sign This Form and Give it to the Receptionist On Your First Visit