River Ridge Veterinary Hospital

6790 River Center Drive
Clemmons, NC 27012

(336)712-3413

riverridgevet.com

New Client Check-In

If you would like to make an appointment, you can assist us to expedite your check in by submitting this form.

Thank you for your cooporation in letting us assist you.

New Client

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Daytime Phone (required)
Phone TypePhone Number (required)
Evening Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Driver's License Number

Employer

Spouse Name
First Name
Last Name
Spouse Phone
Phone TypePhone Number
Emergency Contact Name

Emergency Contact Phone
Phone TypePhone Number
How did you find us? (required) :
Pet's Name (required)

Type of Pet (required) :
Age (years, months)

Sex (required)
Male
Female


Neutered/Spayed
Neutered
Spayed
Intact (not spayed or neutered)


Breed

Coat Color

Microchip Identification Number (if applicable)

Are your pet's vaccines current?
Yes
No


Are medical records at another veterinary practice?
Yes
No


Name of former veterinary practice (city, state)

May we request a transfer of records?
Yes
No


Reasons or conditions that prompted your visit?

List any medications your pet is currently receiving

Does your pet have any known allergies or drug sensitivities?

It is okay for RRVH to use my pet's image on their Website/Social Media pages
Yes
No


Please Read
I understand, by indicating I agree and submitting this registration, that I am responsible for any charges incurred by my pet while in the care of the doctors at River Ridge Veterinary Hospital and that charges are due and payable at the date and time of service. Any balance that is carried over a period of 30 days will accrue a monthly finance charge. Checks returned for non-sufficient funds will incur a $25 fee. Any balance that I leave unpaid will be forwarded to River Ridge Veterinary Hospital's collection agency, and will incur a 25% collection fee for which I am liable, in addition to monthly finance charges.
I have read this statement and -
I Agree
I Disagree



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