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M W F 8 am 5:30 pm T Th 8 am 7 pm Telephone (805) 524-2661 After Hours (805) 223-5996

557 Santa Clara St

Charles E. Lidikay, D.V.M.

Fillmore, Ca 93015 www.FillmoreAnimalHospital.com FillmoreAnimalHospital@yahoo.com

We Treat You and Your Pet Like Family

Fax (805) 524-0211 Thank 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 Spouse/ Co-owner Name Street Address City, Drivers License Number State Zip Email Address Home Telephone Mobile Telephone Work Telephone Home Telephone May We Leave Messages on this line?

Client Registration

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May We Leave Messages on this line?

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May We Leave Messages on this line?

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Ma y We Leav e 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 Referral from a friend or family member


If s o, who may w e thank? How many pets do you own? Previous Veterinarian Information (if applicable): Office Hours

Drive By

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 patience and 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 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 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 true to best of your knowledge.

Please Print and Sign This Form and Give it to the Receptionist On Your First Visit 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 perform certain services. These services may include, but are not limited to, appointment reminders, billing and collections, satisfaction surveys, laboratory services, and consultation services.