Welcome to North Country Veterinary Referral Center (NCVRC).
To ensure the best possible care and service, please take time to complete the following information.

Downloadable form for faxing or uploading

New Client Form

Online Submission

Client Information


Your Name (First and Last required)


Address (required)
Street Address


Street Address Line 2

City

State

Zip Code


Email (required)

Home Phone (required)

Cell Phone

Work Phone

Are you the owner of this pet?
 YES NO

Is the pet co-owned?
 YES NO

Emergency Contact (First and Last)

Emergency Contact Phone

Emergency Contact Email

Patients Information


Patient's Name (required)

Species (required)

Sex
 Male Female

Spayed or Neutered?
 Yes No

Age (required)

Birth Date

If not 100% sure just pick approximate date.

Breed

Color

Is your pet current on vaccinations? (required)
 Yes No

If yes please provide a vaccine certificate.

Accepted file types: jpg, gif, pdf, doc, word, png.
If you do not have the means to provide one electronically then continue without uploading.
If you do not have certification, let the receptionists know and we will verify with your primary care veterinarian.

Primary reason for your visit (required)

Do we have permission to use your pet's case/image on our website or social media?

Referring Veterinary Office


Hospital Name (required)

Referring Doctor

Phone


I authorize the veterinarian/medical staff to examine, prescribe for, or treat my pet. I understand that the estimated fee is based on treatments deemed necessary at the time of admission. I am aware that initial estimate may change due to the status of my pet. I assume responsibility for all charges incurred at the time services are rendered an that I can pay by cash, check, Visa, MasterCard, American Express, Discover, Care Credit or Citi Health Card.