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. "*" indicates required fields Do you currently have an appointment scheduled with a UVS veterinarian?* Yes No Date MM slash DD slash YYYY Please contact UVS 518-783-3198.Client InformationName* First Last Co-Owner Emergency Contact Name Emergency Contact Phone Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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?* Yes No If yes, please tell us the name of the pet Primary Veterinarian InformationA complete set of medical records is required prior to your appointment with a specialist. Please work with your primary veterinarian to make sure these records are received by UVS at least 48 hours before your appointment. Appointments without medical records will need to be rescheduled. Primary 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?* Yes No Species (Please check one)* Canine Feline Breed* Color* Birthday or Age* Gender (Please select one)* Male Neutered Male Unaltered Female Spayed Female Unaltered Authorization 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. EmailThis field is for validation purposes and should be left unchanged.