New Client Information Form Please provide complete information for you, your referring veterinarian and pet. Do you currently have an appointment scheduled with a UVS veterinarian?*YesNoDate Please contact UVS 518-783-3198.Client InformationName* First Last Co-Owner Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* Have you ever been to Upstate Veterinary Specialties?*YesNoIf yes, please tell us the name of the petReferring VeterinarianReferring Hospital*Referring Veterinarian*Pet InformationName* Species (Please check one)*CanineFelineBreed*Color*Birthdate*Gender (Please select one)*Male NeuteredMale UnalteredFemale SpayedFemale UnalteredAuthorization for medical and/or surgical treatment and financial responsibility* I hereby authorize the doctor and designated technicians on duty to administer treatments considered therapeutically necessary. I understand that the estimated fee is based on treatment deemed necessary at the time of admission. In many cases it is impossible to determine in advance full cost of diagnostics and treatment. I understand that all fees are to be paid in full at the time of service. I understand that the hospital requires 24 hours notice for a cancelled appointment, otherwise, I will be responsible for the cost of the appointment time. This iframe contains the logic required to handle AJAX powered Gravity Forms.