New Client Information Form Please complete our New Client Form prior to your visit. A PDF version is available for your convenience. If submitting via PDF, please email to firstname.lastname@example.org or fax to 518-783-3199. Do you currently have an appointment scheduled with a UVS veterinarian?*YesNoDate Date Format: MM slash DD slash YYYY Please contact UVS 518-783-3198.Client InformationName* First Last Co-Owner Emergency Contact NameEmergency Contact PhoneAddress* 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 PhonePreferred Text Confirmation PhoneMust be a phone with text capabilitiesOpt Out: I do not wish to receive text confirmations Email* Have you ever been to Upstate Veterinary Specialties?*YesNoIf yes, please tell us the name of the petPrimary Veterinarian InformationPrimary Veterinary Office*Primary Veterinarian*Pet InformationPet's Name* Photo Release: may we use photo(s) of this patient and information about their case for Public Relations use?*YesNoSpecies (Please check one)*CanineFelineBreed*Color*Birthday or Age*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.