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 ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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? Yes No 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.